STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES Geriatric Mental Health 1. Name of Institution:________________________________________________________________ MCI Reference No.: ________________________________________________________________ 2. Particulars of the Assessor:- Assessment Date_______________________ 3. Institutional Information a). Particulars of college Item College Chairman/ Director/ Medical Health Secretary Dean/ Principal Superintendent Name Address State Pin Code Phone (Off) (Res) (Fax) Mobile No. E.mail: b). Particulars of Affiliated University Item University Vice Chancellor Registrar Name Address State Pin Code Phone (Off) (Res) (Fax) Mobile No. E.mail: SUMMARY Date of Assessment :________________ Name of Assessor :_______________________ Name of Institution Director / Dean / Principal (Private / Government) (Who so ever is Head of Institution) Name Age & Date of Birth Teaching experience
STANDARD ASSESSMENT FORM FOR POSTGRADUATE COURSES Geriatric Mental Health 1. Name of Institution:________________________________________________________________ MCI Reference No.: ________________________________________________________________ 2. Particulars of the Assessor:- Assessment Date_______________________ 3. Institutional Information a). Particulars of college Item College Chairman/ Health Secretary Director/ Dean/ Principal Medical Superintendent Name Address State Pin Code Phone (Off) (Res) (Fax) Mobile No. E.mail: b). Particulars of Affiliated University Item University Vice Chancellor Registrar Name Address State Pin Code Phone (Off) (Res) (Fax) Mobile No. E.mail: SUMMARY Date of Assessment :________________ Name of Assessor :_______________________ Name of Institution (Private / Government) Director / Dean / Principal (Who so ever is Head of Institution) Name Age & Date of Birth Teaching experience