SRI RAMACHANDRA UNIVERSITY (Declared under Section 3 of the UGC Act, 1956) Porur, Chennai

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2 SRI RAMACHANDRA UNIVERSITY (Declared under Section 3 of the UGC Act, 1956) Porur, Chennai Affix passport size photo Application for Admission in ASSOCIATE FELLOW OF INDUSTRIAL HEALTH (AFIH) (All information should be written in CAPITAL LETTERS only) Registration Fee Details: Amount Demand Draft No. & Date Name of the Bank & Branch Rs. 700/- 1. Name : 2. Sex (Male / Female) : 3. Date of Birth : 4. Designation : 5. Employer s Address : 6. Address for Correspondence : with Pin Code & Telephone Number 7. Qualifications (MBBS, PG Degree / Diploma etc.) Examination Passed MBBS Name of the Institution Year of passing % of marks Division / Class MS MD Others

3 8. Experience (Attach certificate(s) from the employer) Name & Address of the employer Post held Period & Duration of experience Whether the industry is a hazardous process industry 9. Whether hostel accommodation required? Yes / No (Indicating Yes does not guarantee accommodation in the hostel) 10. Whether No Objection Certificate enclosed? Yes / No 11. Whether Sponsorship Certificate enclosed? Yes / No I hereby solemnly certify that the information given above is true and correct. Date: Place: Applicant s Signature List of Enclosure: 1. Self-addressed envelope (24cm x 11cm). 2. Demand Draft for Rs.700/- drawn in favour of Sri Ramachandra University, payable at Chennai. 3. Photocopy of MBBS degree (Convocation) Certificate duly attested by a Gazetted Officer. 4. Photocopy of 1 st to final MBBS mark sheets. 5. Photocopy of Internship Certificate issued by the Medical College (not University) duly attested by a Gazetted Officer. 6. Photocopy of MCI/State Medical Council Registration Certificate duly attested by a Gazetted Officer. 7. Photocopy of Experience Certificate duly attested by a Gazetted Officer. 8. Sponsorship Certificate/No Objection Certificate in original, if employed.

4 General Information (to be retained by the candidate) ASSOCIATE FELLOW OF INDUSTRIAL HEALTH COURSE (2013) Recognised by The Directorate General Factory Advice Service & Labour Institutes (DGFASLI), Ministry of Labour, Govt. of India Course will be conducted by Department of Environmental Health Engineering, Sri Ramachandra University World Health Organization Collaborating Center for Research and Training in Occupational Health Center for Advanced Research in Environmental Health for the Indian Council of Medical Research, Govt. of India This 3-month full time program will provide intensive training for medical professionals to acquire skills for occupational health practice. The course contents and curricula have been framed as per guidelines issued by the Academic Council of AFIH, Industrial Medicine Division, Central Labour Institute, DGFASLI, Mumbai. The training will prepare candidates for the qualifying examination to be conducted by the Examination Board of DGFASLI at the end of the 3 month period and successful candidates will be awarded a post graduate certificate entitled ASSOCIATE FELLOW OF INDUSTRIAL HEALTH which will fulfill the requirements in terms of additional qualification of Factory Medical Officers of Hazardous Process Industries as required under the Factories (Amendment) Act, This academic year the program will be administered between December 2, 2013 and February 28th, The program is administered by The Department of Environmental Health Engineering, Sri Ramachandra University with faculty who are well recognized for research and training at the national and international levels. The department is equipped with state-of-the-art occupational health, industrial hygiene and safety laboratory as well as an extensive library. Multi disciplinary research projects, industry linkages and national/international partnerships will provide additional exposure on national /global occupational and environmental issues as well as project opportunities for students. Sri Ramachandra University provides a vibrant student atmosphere with nearly 3400 students enrolled in a range of medical, dental, nursing and allied health sciences programs at the undergraduate, postgraduate and doctoral levels. Dedicated research and sophisticated instrumentation facilities, extensive central library resources and a large 1640-bedded multi-specialty hospital support all academic programs. The lush campus spread over an area of 150 acres provides a range of student facilities including hostel accommodations. Number of Seats : 25 Eligibility for Admission: 1. MBBS Degree from an Institution recognized by the Medical Council of India. 2. Completion of Internship. 3. Permanent Registration with the Medical Council of India/State Medical Council. 4. A minimum of 1 year experience as full-time Medical Officer in an industrial Occupational Health facility or 2 years in general practice, after the date of completion of internship.

5 Selection: Eligible candidates will be admitted after an interview, on the basis of recommendations made by the interview panel. The candidates should bring all the original certificates and documents at the time of admission for verification. Tuition Fee: Rs. 36,500/- including ACLS training (Rs. 30,000/- for candidates already possessing valid ACLS certification) should be paid by Demand Draft drawn in favour of Sri Ramachandra University, payable at Chennai. LAST DATE FOR THE RECEIPT OF DULY FILLED APPLICATIONS: 09 th November, 2013 Applications complete in all respects, along with a Demand Draft for Rs.700/- towards Registration Fee drawn on any nationalized bank, in favour of Sri Ramachandra University, payable at Chennai, and attested photocopies of certificates should reach The Head, Department of Environmental Health Engineering, Sri Ramachandra University, 1, Ramachandra Nagar, Porur, Chennai , Tamil Nadu, by Registered Post, with Acknowledgement Due only. The envelope containing the application should be superscribed APPLICATION FOR ADMISSION TO AFIH Applicants working in Govt. /Public sector undertakings / Autonomous Bodies etc. should apply through proper channel. Incomplete applications will be summarily rejected.