Questionnaire For General Hospitals/Secondary Care Hospitals

Greetings! In an endeavor to present to the nation its finest healthcare providers, CNBC TV18 and ICICI Lombard
are initiating the Healthcare Awards - India's most authoritative awards for the healthcare industry. IMRB
International, Indias leading research agency is powering the robust multi phase methodology that will help
shortlist India's finest healthcare providers for the final round. A panel of the most distinguished names in the
industry and academia will then debate and deliberate to select the final winners across categories.

Please fill the form below to apply into the first phase of the awards.

IMPORTANT: Please fill this form only if you are an authorized representative (eg administrative head or PRO)
of the hospital.

Please note, fill this form only if you are a General/Secondary Care hospital. The definition of such Hospitals is
given below.

A secondary care level hospital is one that does not specialize in treating a specific ailment, but provides
all essential and even some desirable services. Its objective is to provide comprehensive secondary health
care services to the people in the district at an acceptable level of quality and being responsive and
sensitive to the needs of people and referring centers. It provides about 85 90% of medical needs of the
patients. However, for serious illnesses, the patients are referred to tertiary hospitals.

A secondary care hospital may either be a district (government run) hospital or a general (privately run) hospital.

Your hospital needs to meet the following criteria to qualify for these awards.

A. District Hospitals
1. Must be a government run hospital
2. Must fall into Grade I or Grade II or Grade III (i.e.Between 201 500 beds)
3. Provide services as per guidelines specified in IPHS
4. Should not be a super specialty i.e. not more than 75% of patients should be treated for a single specialty
(such as cardiology, neurology etc.)
5. Must not have a medical college or university attached.

B. General Hospitals
1. Must be a private hospital
2. Must have between 101 200 beds
3. Must have been in operation for at least 2 years (i.e. operational since July 2010)
4. Provide services as per guidelines specified in IPHS
5. Should not be a super specialty i.e. not more than 75% of patients should be treated for a single specialty.
(such ascardiology, neurology etc.)
6. Must not have a medical college or university attached.

Thank you for your time and participation. LAST DATE TO SUBMIT THE FORM IS 30th September 2012

1. Please fill out the following details about yourself.

Name .....................................................................................................................................................................................
Designation ................................................................................ Email ID ............................................................................
Telephone ........................... Mobile ........................... Years worked at current hospital ........ Total years of experience ....
2. Please fill out the following details about your hospital.

Name of the hospital .....................................................................................................................................................................

Address 1 ......................................................................................................................................................................................
Address 2 ......................................................................................................................................................................................
Nearest landmark............................................................... City .......................... State..............................Pin Code ..................
Website .........................................................................................................................................................................................

3. The following table contains a list of parameters regarding hospital capacity. Please fill in the grid below.

No. of General Wards / Classes ............. No. of functional beds in General Wards .............
% Occupancy of beds (in the last one year) ............. No. of Special Wards / Classes .............
No. of functional beds in Special Wards ............. No. of Emergency Wards ............
No. of functional beds in Emergency Wards ............. No. of ICU .............
No. of functional beds in ICU ............. No. of Labour Rooms (only for Gynaecology & Obstetrics) .............
No. of minor Operation Theaters ............. No. of major Operation Theaters .............
OPD Capacity per day ............. No. of Ambulances .............
No. of free of cost beds ............. Total number of beds .............
No. of Operation Theaters .............

4. Please place a TICK in the box on the right if your hospital has the following facility.

Histo Pathology Laboratory Radio Immuno Assay CT Scan

MRI Blood Bank Documented Infection Control Policies/
Manuals
Computerized Billing X-ray Facility Sonography
Integrated Hospital Information Systems (in addition to computerized billing)
ECG Endoscopy Imaging Services

List of other major equipment (e.g. PET Scan or any other special investigation equipment)
(Please feel free to attach an excel sheet if you wish to list more equipment

5. Please TICK the term that best describes the ownership structure of your hospital.

Partnership Government Co-operative

Trust Corporate Proprietorship

6. How many patients does your hospital treat in a typical ONE-MONTH period?
Please fill in the box below

No. of outpatients (Non-admitted patients) ......................... No. of admitted patients...........................................................

No. of emergency cases registered...................................... No. of emergency cases admitted...........................................
No. of patients treated free of cost in OPD ......................... No. of admitted patients treated free of cost .........................

7. And what is the number of full-time staff, part-time staff, doctors and
nurses employed by your hospital? Please fill in the box below.

Full-time staff ......................... Part-time staff ......................... Visiting doctors .........................

Specialist Doctors affiliated to your hospital only ......................... Nurses .........................
8. Now we would like to ask you a few questions regarding the services offered by your hospital.

No. of surgeries performed per month

superspeciality
hospitals

9. Please tell us whether you have the following facilities in your hospital.

Reception / Helpdesk/ Desk Cafeteria / Canteen Insurance desk

Pharmacy inside the hospital

10. Please place a TICK against the activity in which your hospital is involved.

Clinical Trials of New Drugs Experimental Surgery

Facility / Lab for Research & Development Disease Management Programmes
Disability Certification Services Health Promotion and Counseling Services
 11. Please list the support services available in your hospital.

Support Service :

Ambulance Service Catering Laundry Management

Management of Bio-medical waste Social Service Bio- Medical Engineering

Human Resources Maintenance & Facilities Management like housekeeping etc.

Blood Bank Information Technology Mortuary Services

24hours Security Supply chain Management/ Material Management System

12. Please list any Industry Accreditations/Awards or Recognition your hospital has won.

Name of Accreditation / Award won Year

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13. Could you please provide a list of empanelled doctors attached to your hospital along with their
contact information in the grid below.

Specialty Name Qualification Contact Info (Phone, Mobile, Email)

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Please send in your completed forms to:

Ms.Chhaya Jadhav, Television Eighteen India Ltd., Empire complex, 414 First Floor, Senapati Bapat Marg,Lower Parel,
Mumbai 13. Contact - email us at healthrsvp@network18online.com or log on to http://hca.moneycontrol.com