Information in below mentioned table is required to be filled by NBE appointed Assessor only:
MANIPAL HOSPITAL SARJAPUR
Name of the Hospital/Institute
Assessment conducted for the
Programme of
Date of Assessment
Mark for
Eligibility as per NBE norms
Acceptability
Proposed Faculty is Accepted for Senior Consultant
aforesaid Programme as Junior Consultant
Senior Resident
Not Accepted
Name of the Assessor
Signature of Assessor
DECLARATION FORM – FACULTY/SENIOR RESIDENTS
It shall be the responsibility of Head of the Institute and designated Head of the Applicant
Department that faculty declarations are completed and submitted only for those faculty in the
department who are employed on “FULL TIME” basis. Please do not submit faculty declarations for
Part time/Visiting/Adjunct faculty in the department.
The maximum eligible age to qualify as faculty for DNB/FNB programme, at the time of application
submission, is 75 years. Please ensure that faculty declarations are not completed & submitted for
faculty who have attained an age of 75 years at the time of application submission.
The proposed faculty shall be in possession of minimum eligible qualifications as prescribed by NBE
which is duly recognized as per provisions of IMC act.
Faculty Declaration for seeking NBE Accreditation in the specialty of __________ at
__________________________ (Hospital / Institute).
PERSONAL INFORMATION:
1. Name of the faculty: Dr Harshavardhan Rangappa Kuri
2. Designation in the applicant Associate consultant – Critical Care
hospital/Institute: Medicine
3. Date of Birth (DD-MM-YYYY): 12.07.1991
Photo
4. PAN Number:
5. Faculty Eligibility as per NBE
norms:
6. Photo ID Proof issued by Photo ID Photo ID Number Issuing Authority
Government Authorities PAN
Card/Adhaar Card/Passport
etc.
7. Present Residential Address Flat 561 , wing 5 , floor 6 , uber verdant phase 1 , sarjapura main
of Faculty: road , Bangalore
8. Permanent Residential Flat 561 , wing 5 , floor 6 , uber verdant phase 1 , sarjapura main
Address of Faculty: road , Bangalore
9. Contact Particular
Telephone (Office) Mobile Number Alternate Mobile Email ID
(With STD Code) Number
9164250071 [Link]@[Link]
10. PROFESSIONAL QUALIFICATIONS (In Chronological Order MBBS onwards):
Area of Year Name of the Medical Qualificatio Name Registratio
Course Name specialization of College/Hospital/Institu n of the n Valid
(eg. MBBS, Passin te with City & State Registration Medica upto
DNB/MD/MS g Number l (month &
/ DM/ MCh Council Year)
etc.)
MBBS 2014 Belgaum institute of KMC111020 KMC
medical sciences
DNB anesthesiology 2019 P.D Hinduja hospital , KMC KMC
mumbai 111020
DM Critical care 2024 AIIMS jodhpur KMC111020 KMC
medicine
FCCU- Ultrasound and 2024 ISCCM
Fellowship in Echocardiograph
Critical care y
Ultrasound
11. EXPERIENCE AFTER PG DEGREE QUALIFICATION
Post PG Degree Experience (in Years):
Period of Employment Designatio Hospital/ Departme Employme Hours Whether
Present/Past n Held Institute nt nt Status Spent associated
Presen From To Name with per with
t/ Past (Mont (Mont City &State Day DNB/FNB
h- h- (appr programme
Year) year) ox.)
Jan Feb ICU Manipal
2020 2020 Registrar Hospital
Whitefield
2021 2024 Senior AIIMS Jodhpur Intensive
Resident – Care
Intensive Medicine
Care
Medicine
Presen Associate Manipal Critical
t Consultant Hospital Care
– Critical Sarjapura Medicine
Care
Medicine
2021 2024 Senior AIIMS Jodhpur Intensive
Resident – Care
Intensive Medicine
Care
Medicine
Before joining present institution, I was working at ___________________________as ________________and
relieved on _________ (dd-mm-yyyy) after resignation /retiring .
12. Research Activities of Faculty:
(Details of maximum 5 latest Research Activities)
Research Publication (Vancouver citation style) Nature of Research Activities
Effects of Early Use of Methylene Blue and Vasopressin on Randomized Controlled Trial [cite:
Noradrenaline Dose in Septic Shock: A Randomized Controlled Trial 53]
– Indian Journal of Critical Care Medicine, 2025 | DOI: 10.5005/jp-
journals-10071-24905 [cite: 53, 54]
Delayed Diffuse Alveolar Hemorrhage in Echis sochureki Case Report/Observation (Implied
Envenoming, Jodhpur, India – American Journal of Tropical Medicine by title and nature) [cite: 55]
and Hygiene, Jan 2022 | DOI: 10.4269/ajtmh.21-1187 [cite: 55, 56]
Creutzfeldt-Jakob Disease: A Rare Disorder – A Common Malingerer (Not explicitly mentioned in the CV)
– Research and Opinion in Anesthesia & Intensive Care Journal [cite: [cite: 57]
57]
Presentation (Paper / Poster):
Name of Presenter Title of the Date of Name of Conference Nature of
Presentation Presentation Presentation
13. FACULTY AS THESIS GUIDE:
(Details of Maximum 5 Thesis guided by the faculty. Please do not include details of thesis wherein faculty
acted as a Co-Guide)
Course Specialty Name of the Thesis Topic Period of Year of Thesis
Candidate Thesis Acceptance
Guidance in
Year
14. Please indicate experience of faculty in conducting Theory/Practical Examinations and Accreditation
Assessment of hospitals for NBE and other Universities. (Maximum in 1000 characters):
15. Please indicate significant contributions of faculty to academic activities of NBE or other universities in
earlier years: (Maximum in 1000 characters)
16. The faculty has drawn total emoluments from the applicant hospital / institute in current financial year
as under:
Month & Year Remuneration drawn from the TDS
Applicant Hospital / Institute
I hereby declare that:
1. I, _________________ am working as ______________ in the department of ______________
at __________________ (Hospital / Institute) and do hereby undertake that I am a full-time
faculty at above mentioned hospital / institute and working from____ AM to ____ PM daily at
this hospital / institute.
2. I have not presented myself as faculty to any other hospital / institute / medical college
concurrently for the purpose of NBE/MCI/any other accreditation for any academic programme.
3. I am not having Private Practice anywhere, OR
I am practicing at _____________ (Address of Private Practice) in the city of _________ in an
independent set up. My hours of private practice are _____ to _____.
4. It is also to confirm that the above-mentioned department at this Institution/ Hospital is my
principle place of practice and I have no other institutional attachment / affiliation (except my
own private practice in a non-academic independent setup, if so, indicated above.). Further, I
have not proposed / applied / counted as a faculty for any other DNB / MD / MS / Diploma / DM
/ MCh / Equivalent programme in this hospital / institute or any other hospital concurrently.
5. Further, I state that I am not working in any hospital / institute other than the applicant hospital
/ institute in any capacity viz Regular / Contractual / Adhoc / Full time / Part time / Honorary
etc.
6. Complete details with regard to work experience have been provided and nothing has been
concealed by me.
7. It is declared that each statement and/or contents of this declaration and/or documents,
certificate submitted along with declaration form, by the undersigned are absolutely true,
correct and authentic.
8. In the event of any statement made in this declaration subsequently turning out to be incorrect
or false, the undersigned has understood and accepted that such misdeclaration in respect to
any content of this declaration shall also be treated as a gross misconduct thereby rendering the
undersigned liable for necessary disciplinary action (including removal of name from Indian
Medical Register).
9. I have gone through the Information Bulletin for Accreditation with NBE and hereby agrees to
impart DNB/FNB training to DNB/FNB trainees as per prescribed NBE guidelines.
Date: Signature of the Faculty: __________________________
Place: Name of the Faculty: __________________________
ENCLOSURES
(Following documents are required to be provided to NBE appointed Assessor at the time of assessment)
Sl No. Documents Submitted
Recent Passport size photo of the faculty, signed by HOI of
1. Yes / No
Hospital/Institute/Medical College
Photo ID proof issued by Government Authorities: Passport/PAN
2. Yes / No
Card/Voter ID card/Aadhar Card
Certified copies of present appointment order at present
3. Yes / No
Hospital/Institute/Medical College
Copy of Passport/Voter ID/ Electricity Bill/Telephone Bill/Aadhar
4. Yes / No
Card as proof of present residence
5. Joining Report at the present hospital/institute Yes / No
6. Copy of Degree Certificates of eligible PG Degree qualification Yes / No
Copy of Additional Qualification Registration Certificate for eligible
7. Yes / No
PG Degree qualification
8. PAN card Yes / No
Form 16/16A issued by the applicant hospital for AY 2019-20
(download from the website of TRACES)
9. Yes / No
Only in case of faculty joining the applicant hospital after March
2019, please submit Statement of bank transfer since joining till
date
Signature of Faculty: _____________________________
ENDORSEMENT BY HEAD OF THE DEPARTMENT & HEAD OF THE INSTITUTE:
This endorsement is the certification that the undersigned has satisfied himself / herself about the
correctness and veracity of each content of this declaration and endorse the above mentioned
declaration as true and correct. I have verified the certificates/documents submitted by the faculty
with original certificate/documents as submitted by the faculty to the hospital / institute / medical
college and found them to the correct and authentic.
I also confirm that ___________________ is not practicing or carrying out any other activity during
hospital / institution / medical college working hours i.e. from _____AM to ____ PM since he / she
has joined the institute.
The faculty has undertaken that He/She is not working at any hospital / institute other than this
hospital and other than his/her private practice in an independent setup.
In the event of this declaration turning out to be either incorrect or any part of this declaration
subsequently turning out be incorrect or false it is understood and accepted that the undersigned
shall also be equally responsible beside the declarant himself / herself for any such misdeclaration of
misstatement.
Signature of Head of the Signature of Head of the Institute
Department with official Stamp
_______________________
Signed & Verified by NBE
Appointed Assessor