SECTION A (Personal Details)

Transcription

1 SECTION A (Personal Details) 1. Name(please use block letters): Paste Photo (Title) - (First name) - (Middle name)- (Last name) 2. Date of Birth (dd/mm/yyyy): 3. Nationality: 4. Present position/appointment: 5. Workplace address(including Organization Name): Telephone (+91) Fax (+91) 6. Residential address: Telephone (+91) 7. Preferred address for correspondence (please indicate) Home Work 8. Mobile: +91

2 9. Educational Qualifications (starting from graduation): Year Degree/Diploma Institution Major or Specialization 10. List any other significant certifications including courses (special reference to NABH and other assessor/auditor courses attended): Year Course/ certificate Institution/Organization/ Body Subject/ Area 11. List all currently held professional registrations: Registration (please mention name of degree) Registration body Registration number Validity (where applicable) 12. Professional Experience (Describe all formal positions held beginning with the present position): Sl. No. Date (from - to) Employer Position Key Responsibilities

3 13. Other relevant experience and achievements including contributions to health field (e.g. standards body membership; experience as a trainer in the area of accreditation; awards): 14. Computer skills (PowerPoint, Internet, , Messenger, Word, Excel etc.): 15. Language skills (specifically state languages which can be spoken and/or read):

4 SECTION B (Statement of Purpose) Please set out below (no more than 500 words) What interests you in becoming an NABH assessor Description of your aptitude and competency for engaging in NABH assessments (please refer to Core Competencies expected in an Assessor as mentioned in the NABH website)

5 SECTION C (Referees) Please list below two referees (Professionals who have had a working relationship, preferably as a senior, with the applicant for at least six months) 1. Name Telephone (+91) Fax (+91) Mobile (+91) Briefly indicate how you know the referee: 2. Name Telephone (+91) Fax (+91) Mobile (+91) Briefly indicate how you know the referee:

6 SECTION D (Self statement & declaration) I, the applicant, have read the expected competencies and commitments required of NABH Assessor and I am able to comply if selected as an Assessor. Further, I hereby certify that all of the information that I have provided on this Application is true and accurate to the best of my knowledge, information, and belief. I understand that NABH has the right to refuse or decline any application without assigning any reasons for the same. I shall be responsible for ensuring that the necessary approvals (where applicable) are obtained for participating in the assessor training program (if selected for the same) and assessments. I understand that NABH may contact the Referees mentioned above for more information. Signature of applicant Date PLEASE INCLUDE WITH THIS APPLICATION THE FOLLOWING: Self attested copies of Degree/Diploma Certificate(s) Training Certificate(s) Registration Certificate(s) (where applicable) Photo ID proof National Accreditation Board for Hospitals and Healthcare Providers (NABH) Quality Council of India 5th Floor, ITPI Building 4A, Ring Road, IP Estate New Delhi Ph.: , , , , , Extn. 40 Fax: info@nabh.co Website: