AYJNISHD

Applicant Panel - Apply for Cochlear Implant Surgery
(Parents / Applicant Panel Registration & Login)

Hospital Panel
(Empanelled Hospitals & Surgeons)

Audiologist Panel
(Empanelled Activation & Mapping centres)

Habilitationists/Therapist Panel
(Empanelled ASLP, AVT’s & Special Educators(HI))

Check Application Status
(With Registration Number)

Check Application Status

Empanelled list

Reports

Cases scheduled / waitlisted for Cochlear Implant
Details of cases undergone Cochlear Implant Surgery (MIS Reports which are only for internal use are Password protected)

APPLICATION FORM FOR EMPANELMENT OF HOSPITALS AND SURGEONS FOR CONDUCTING COCHLEAR IMPLANT SURGERY UNDER REVISED ADIP SCHEME (2014-15)

DETAILS OF HOSPITAL

Name of the Hospital: *

Date of Establishment:

Registration Number:

State:

Address:

Telephone Number:

Mobile Number:

E-mail ID of Hospital:

E-mail ID of ENT Surgeon Attached with the Hospital:

Contact Person for Co-ordination:

Number of Full Time ENT Faculty:

Approximate Otology Workload at the Hospital in a Month:

Any Academic Programs at the Hospital:

Availability of Radiology Services at the Hospital:

Availability of Critical Care Unit/PICU with Ventilator:

Availability of Anesthesia Services at the Hospital:

Audiology Services:

Rehabilitation Services:

DETAILS OF CI SURGEONS ATTACHED TO THE HOSPITAL

Surgeon 1

Name:

Qualification:

MCI registration number:

Frequency of Visit to the Hospital:

Number of Years of ENT Experience:

Number of Years of Experience in CI Surgery:

Worked in CI center/ Fellowship:

Yes

Surgeon 2

Name:

Qualification:

MCI registration number:

Frequency of Visit to the Hospital:

Number of Years of ENT Experience:

Number of Years of Experience in CI Surgery:

Worked in CI center/ Fellowship:

Yes

Surgeon 3

Name:

Qualification:

MCI registration number:

Frequency of Visit to the Hospital:

Number of Years of ENT Experience:

Number of Years of Experience in CI Surgery:

Worked in CI center/ Fellowship:

Yes

DETAILS OF AUDIOLOGISTS ATTACHED TO THE HOSPITAL

AUDIOLOGIST 1

Name:

Qualification:

RCI Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

AUDIOLOGIST 2

Name:

Qualification:

RCI Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

AUDIOLOGIST 3

Name:

Qualification:

RCI Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

DETAILS OF HABILITATION PROFESSIONALS/SPEECH-LANGUAGE PATHOLOGISTS (SLPs) /AUDITORY VERBAL THERAPISTS (AVTs) ATTACHED TO THE HOSPITAL

PROFESSIONAL 1

Name:

Qualification:

Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

PROFESSIONAL 2

Name:

Qualification:

Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

PROFESSIONAL 3

Name:

Qualification:

Registration Number:

Number of Years of Experience with CI:

Frequency of Visit to the Hospital:

DETAILS OF OTHER REHABILITATION PROFESSIONALS ATTACHED TO THE HOSPITAL

PSYCHOLOGIST

Name:

Qualification:

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

MEDICAL SOCIAL WORKER

Name:

Qualification:

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

ANY OTHER

Name

Qualification

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

DETAILS OF OTHER MEDICAL PROFESSIONALS ATTACHED TO THE HOSPITAL

PEDIATRICIAN

Name

Qualification

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

NEUROLOGIST

Name

Qualification

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

RADIOLOGIST

Name

Qualification

Registration Number

Number of years of Experience with CI

Frequency of visit to the hospital

MENTOR SURGEON DETAILS (IF ANY)

Name:

Qualifications:

MCI Registration Number:

Experience in CI Surgery:

Number of Implants done:

Frequency of Visit:

Attach consent from mentor surgeon to support the program at your hospital. Attach relevant certificates.

File Name	Upload
1. Consent from Mentor Surgeon*	File size exceeds 2 MB.
2. Other Certificate

Any hospital providing false information shall be viewed seriously and can amount to cancellation of accreditation. Accreditation can also be cancelled on recommendations of expert advisory panel in case of audit failure.

I, hereby declare that the above-stated information is true and I am willing to provide the services at the rate as per ADIP CI guidelines.

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Registered for CI

CI Surgery done

Hospitals Empanelled

Audiologists Registered

Habilitationists Registered

Updated:

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Ministry of Social Justice & Empowerment

AYJNISHD

Rehabilitation Council Of India

Jobs for Hearing Impaired

Cochlear Implant under ADIP Scheme of Government of India

Ali Yavar Jung National Institute of Speech and Hearing

Disabilities (Divyangjan), Mumbai

Surgeon 1

Surgeon 2

Surgeon 3

AUDIOLOGIST 1

AUDIOLOGIST 2

AUDIOLOGIST 3

PROFESSIONAL 1

PROFESSIONAL 2

PROFESSIONAL 3

PSYCHOLOGIST

MEDICAL SOCIAL WORKER

ANY OTHER

PEDIATRICIAN

NEUROLOGIST

RADIOLOGIST

PART A

Manufacturer

No. Of units

Since when

Last Serviced

PART B

Details

PART C

Staff Number available

Diagnostic

Medical

Post-implant Rehabilitation

Registered for CI

CI Surgery done

Hospitals Empanelled

Audiologists Registered

Habilitationists Registered

Updated:

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Surgeon 1

Surgeon 2

Surgeon 3

AUDIOLOGIST 1

AUDIOLOGIST 2

AUDIOLOGIST 3

PROFESSIONAL 1

PROFESSIONAL 2

PROFESSIONAL 3

PSYCHOLOGIST

MEDICAL SOCIAL WORKER

ANY OTHER

PEDIATRICIAN

NEUROLOGIST

RADIOLOGIST

PART A

Manufacturer

No. Of units

Since when

Last Serviced

PART B

Details

PART C

Staff Number available

Diagnostic

Medical

Post-implant Rehabilitation

Registered for CI

CI Surgery done

Hospitals Empanelled

Audiologists Registered

Habilitationists Registered

Updated: var currentTime = new Date() var month = currentTime.getMonth() + 1 var day = currentTime.getDate() var year = currentTime.getFullYear() document.write(month + "/" + day + "/" + year)

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