APPLICATION FOR REGISTRATION OF TISSUE BANKS OTHER THAN EYE BANKS

(To be filled by head of the institution) (See rule 24(1)) The Appropriate Authority for organ transplantation..................... (State or Union Territory) We hereby apply to be registered as Tissue bank , Name : Name(s) of tissue (s)(Bone, heart valves, skin, cornea etc) for which Registration is required The required data about the facilities available in the institution are as follows:- A. General Information : 1. Name 2. Address 3. Government/Private/NGO 4. Teaching /Non- teaching 5. Approached by: Rail: Yes No Road: Yes No Air: Yes No 5.Information Education and Communication ( IEC) for Tissue Donation 6.Type of tissue bank: Auto Logons /Allograph/Both B. DONOR SCREENING REMOVAL OF TISSUE AND STORAGE: 1. Availability of adequate trained and qualified Personnel for removal Tissue ( annex detail). 2. Names, qualification and address of the doctors/technician who w ill be doing removal of tissue. (annex details) 3. Facilities for removal of Tissues 4. Whether register of recipient waiting list available. 5. Telephone arrangement available. Yes/No ( Telephone Number.....................) 6. Availability of ambulance/ vehicle or funds to Pay taxi for collecting tissue from outside: Yes/No 7. Sets of instruments for removal of tissue Yes/No 8. Facilities for processing of tissue Yes/No 9. Refrigerator for preservation of tissue Yes/No 10. Special containers for preservation of tissue during transit. Yes/No 11. Suitable preservation media Yes/No 12. Any other specific requirement as per tissue Yes/No C.PRESERVATIONS OF TISSUE Arrangement of preservation of Tissue Yes/No D.RECORDS 1. Arrangement for maintaining the records Yes/No 2. Arrangement for registration of cases, donors Yes/ No and follow up of cases. E. EQUIPMENT: Instruments specific for the tissue Yes/No F. LABORATORY FACILITIES(If the information is exhaustive please annex it) a. Names of the investigations carried out in the department. b. Facility for testing for : i. Human Immunodeficiency Virus Type I and II ii. Hepatitis B Virus - HBc and HBs iii. Hepatitis C Virus - HCV iv. Syphilis - VDRL c. If no where do you avail it ? Please mention name and address of institute. d. Facility for culture and sensitivity of tissue Yes/No G. OTHER PERSONNEL 1. No. of permanent staff member with their designation. 2. No. of temporary staff with their designation 3. No. of trained persons ANY OTHER INFORMATION The above said information is true to the best of my knowledge and I have no objection to any scrutiny of our facility by authorised personnel. A Bank Daft/cheque of Rs. 10,000/ (for new registration) and Rs. 5,000 (for renewal) in favour of _______ is enclosed. Sd/- HEAD OF THE INSTITUTION