PROFORMA FOR TERTIARY CANCER CENTRE

THIS FORM IS IN FIVE PARTS : I. II. III. IV. V. To collect detailed information about Institution, Application for grant-in-aid (Action Plan) State Govt. Recommendation Memorandum of Understanding Inspection report (to be completed by central team)

PART I 1. 1.1 Name and address of Institute/Medical College/Govt. Hospital RNT Medical College,Udaipur Nature of the organization (whether NGO(existing RCC only)/ Govt. Institution/ Autonomous Govt. Body/PSU etc.) Government Institution 2. 2.1 Details of infrastructure: Own building/rented building Total number of Indoor-beds : In the entire hospital 1146 2.2 Bed for cancer patients 48 2.2.1. already available : 48 2.2.2. proposed full strength 2.2.3. Number of beds within the RCC structure/complex 2.2.4. Day Care Facilities : Chemotherapy

3.

Facilities for management of cancer patients* Service Existing Proposed Head of Service Name/Qualification/ Experience

1.

Pathology
-

Histopathlogy Cytology Haematology Blood Bank

Available Available Available Available Available Available

Dr.N.N.Mogra M.D. (prof. and head )

2. 3.

Microbiology Biochemistry

Dr.A.S.Dalal M.D. (prof. and head ) Dr.A.K.Verma M.D. (prof. and head )

4.

Radio-diagnosis

Dr.M.L.Meena M.D. (prof. and head )

X Ray Ultrasound CT Scan

Available Available Available N/A Available N/A N/A N/A

5.

Surgical Oncology - Head & Neck - General - Gynaecology - Specialised

6.

Medical Oncology

7. 8. 9.

Paediatric Oncology Pain and Palliative Radiotherapy

N/A Available Available Dr.Ajay Sharma M.D. (prof. and head )

10. 11.

Radiation Physics Anaesthesiology

Available Available Dr. P.Bajaj M.D. (prof. and head )

12. 13. 14. 4. 4.1

Cancer Registry For city/Records Medical Records Any other

Available Available

Patient population Data Districts and region covered by TCC (give details): Rajsamand,Dungarpur,Banswara,Chittorgarh,Udaipur,Pratapgarh Bhilwara to be covered under T.C.C.

4.2 4.3 4.4

Population in the above districts and region: 1,22,36014 Expected number of new cases of cancer per year: 1800 (approx.) Registered new case/year in last years (for existing cancer dept.) 2008 2009 2010 1761 708 : Yes

4.5 4.6

Payment for treatment by patients (percentage) User charges levied or not (If yes give details) For cobalt therapy Rs 700 for Radical treatment And Rs 250 for Palliative treatment

5.

Radiotherapy facilities Existing (Number) One N/A N/A N/A Proposed # (Number)

Equipments - Cobalt - Linear Accelerator

- Manual Brachytherapy - Simulator - Radiation Physics Survey meter Other instrument 6.

- Remote A/L Brachytherapy Available - Treatment Planning System Available

Surgical Oncology No. of Operation Theatres General Surgery Cancer Surgery Medical Oncology No. of beds in Medical Oncology No. of new patients treated with Chemotherapy 2008 2009 2010 880 560 N/A One N/A

7.

Details of courses in Medical Oncology

N/A

8.

Teaching Programme Course Duration Seats/Year 3 Yrs One Affiliation Existing/Proposed Proposed

Speciality

- Radiotherapy M.D. - Surgical Oncology N/A - Medical Oncology N/A - Palliative Care - Radiation Physics - Technologist (Specify) - Nursing - Other (Specify) 9. 9.1 9.2 N/A N/A N/A N/A - Cancer Epidemiology N/A

Medical University Of Rajasthan

Research and Training Activities Mention in Brief Continuing/proposed research works in cancer epidemiology, basic sciences, clinical sciences etc. mention in brief training activities and community oriented programmes (within and outside the RCC). It will provide cancer care ranging from cancer prevention , early detection , diagnosis , provision of therapy , after care , palliative care and rehabilitation.

9.3

Research Publications already carried out (attach separate list, if any) N/A

PART-II PROPOSAL FOR OBTAINING GRANT-in-aid (Action Plan) Equipments can be procured for Radiotherapy/Surgical Oncology/Medical Oncology/Pathology/Radio-diagnosis/Nuclear Medicine etc. (refer annexed indicative list) 10. 10.1 10.2 10.3 10.4 10.5 11. 11.1 11.2 11.3 11.4 11.5 12. 12.1 12.2 12.3 13. 13.1 13.2 14. Radiotherapy (Teletherapy/Branchytherapy) Equipment Estimated cost of Equipment Building for Equipment Approval by AERB/BARC Building Plan of TCC Building Plan for Proposed Eqipment Medical Oncology/Palliative care Medical Oncologist/dedicated physician or surgeon Palliative Care Physician/Surgeon or PMR specialist Dedicated day care ward/facility for chemotherapy Dedicated palliative Care ward of Rehabilitation ward Chemotherapy drugs/consumables Surgical Oncology Surgical Oncologist/Trained Surgeon Dedicated Operation Theatre/OT table Special Surgical equipmens like endoscopy/knife etc. Diagnostic/pathology/other equipments estimated cost Other details Timelines (Gantt Chart) for different stages of completion of action plan : : : : 10 Crores (aprox.) under construction not obtained not attached not attached

Mention details of any previous grants taken earlier and the status of its Utilization Certificate. Date: Name and Seal of Head of TCC/Institution P.S. If it is a govt./govt.-undertaking institution, the proforma should be

forwarded by competent authority. Attach separate sheets to provide information wherever necessary.