Data Collection Tool - Form 01
Version: 1.11, Date: 08 May 2014
Directorate of Nursing Services
Photo
Data Collection Tool
Current Facility Name:_______________________ District:_____________
General Information
Type of Staff (Tick):
Nurse
Non-Nurse
Primary BNC Registration No.:
National ID No.:
Department:
If Nurse, please tick:
Admin
Service
Department:
Teaching
Admin
If Non-Nurse, please tick:
Support Staff
Personal Information
Full Name (English)
Name (Bangla)
(Capital Letter)
Male
Sex (Tick)
Female
Passport Number
Father’s Name
Mother’s Name
Date of Birth
Birth Place (District)
(Day)
Religion (Tick)
(Month)
(Year)
Marital Status (Tick)
I
Hi
Bu
Ch
S
M
W
D
Se
O
S=Single, M=Married, W=Widow, D=Divorced, Se=Separated
I=Islam, Hi=Hindu, Bu=Buddhist, Ch=Christian, O=Others
Mobile Number
E-mail Address
Name of Spouse
Occupation of Spouse
No. of Children
Children Educational Allowance
TK.
No.
Official Information
Type of Post (Tick)
C
RP
RT
D
C=Cadre, RP=Revenue Permanent, RT=Revenue Temporary, D=Development
Category of Class (Tick)
I
II
III
IV
I=Class-I, II=Class-II, III=Class-III, IV=Class-IV
Gradation Number:
wet `ªt
GB WvUv Kv‡jK&kb Uzj (wWwmwU) G †gvU 4wU dg© Av‡Q| d‡g©i cÖ_‡gB eZ©gvb Kg©¯’‡ji bvg Ges Kg©¯’‡ji ‡Rjvi bvg wjL‡Z n‡e| †h me RvqMvq
(Tick) ‡jLv Av‡Q †m me ¯’v‡b mwVK Ack‡b wUK wPý w`‡Z n‡e| Primary BNC Registration No. Gi e‡· 3rd year Gi weGbwm ÷vd
†iwR: bs wjL‡Z n‡e hv cÖwZ 5 eQi ci ci bevqb Ki‡Z nq|
1
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)
Mailing Addresses
Present
Permanent
Village/House/Road
Division
District
Thana/Upazilla
Post Office
Postal Code
General Educational Qualification
Level of Education
1
Board/University/Institute
Division/Class/CGPA
Year
Country
2
3
4
5
SSC
O Level
Dakhil
Equivalent
HSC
A Level
Alim
Equivalent
Graduation:
BA
B.Sc
BSS
Fazil
Others
Masters:
MA
M.Sc
M.Com
Kamil
Post graduate (Diploma)
wet`ªt Mailing Addresses G †gvU 6wU Ackb Av‡Q| Present (eZ©gvb) Ges Permanent (¯’vqx) wVKvbv †jLvi Rb¨ D³ 6wU AckbB e¨eüZ
n‡e| hw` †KD Zvi Postal Code bv Rv‡bb Zvn‡j RvqMvwU duvKv ivL‡eb| Gici `yB ai‡bi GWz‡Kkb †Kvqvwjwd‡Kkb †Uwej Av‡Q| 1g wU n‡jv
General Education Qualification Ges 2q wU n‡jv Professional Education Qualification †Uwej| Dfq †Uwe‡j †gvU 5wU Kjvg
Av‡Q| hv wb‡¤œv³fv‡e cyiY Ki‡Z n‡et 1bs Kjv‡g GWz‡Kkb †j‡fj ‡÷Uv‡mi †h AckbwU Avcbvi Rb¨ cÖ‡hvR¨ Zvi cv‡k¦© Aew¯’Z e‡· wUK wPý w`b|
Gici 2 bs Kjv‡g †h †evW© ev cÖwZôvb †_‡K Avcwb cvk K‡i‡Qb Zvi bvg wjLyb| 3 bs Kjv‡g Avcbvi djvdj wjLyb| 4 bs Kjv‡g cv‡ki eQi Ges †kl
A_©vr 5 bs Kjv‡g †h †`‡k ‡jLvcov K‡i‡Qb Zvi bvg wjLyb| D³ †Uwe‡ji cÖwZwU jvB‡bi †¶‡Î GwU cÖ‡hvR¨ n‡e|
2
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)
Professional Educational Qualification
Level of Education
Diploma
Board/University/Institute
Division/Class/CGPA
Year
Country
Nursing
Midwifery
Orthopedic
Others
If others, specify:__________________
Graduation
B.Sc in Nursing (Basic)
B.Sc in Nursing (Post-Basic)
B.Sc in Nursing/
Public Health Nursing
Post graduate (Professional Degree):
Masters in Nursing
Midwifery
Community
Health
Pediatric
Medical & Surgical
Nursing
MPH
Masters in International Health
MEd for PHC
MCH
Others
If others, specify:__________________
PhD
BNC Registration Information
Type of Registration
Reg. Number
First Issue Date
dd/mm/yyyy
Last Renewal Date
dd/mm/yyyy
Diploma in Nursing
/
/
/
/
Diploma in Midwifery
/
/
/
/
B.Sc in Nursing (Basic)
/
/
/
/
B.Sc in Nursing/Public Health Nursing
/
/
/
/
Others (Specify):_____________________________
/
/
/
/
BNC Registration Information ‡Uwe‡j evsjv‡`k bvwms KvDwÝj †_‡K wewfbœ wel‡qi Dci cÖvß †iwR‡óªkb bv¤^vi, Bmy¨ Ges bevq‡bi ZvwiL wjL‡Z n‡e|
3
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)
Data Collection Tool - Form 02
First Service Information
Date of 1st Appointment
G.O. No. of
1st Appointment
(Day)
(Month)
(Year)
Service Particulars (Posting/Transfer/Deputation/Promotion/Lien) (In ascending order to present posting)
(Use extra sheet, if needed)
SL
#
1
Designation
&
Designation
Status*
2
*Designation
Status
**Workplace
Category
Workplace
Category**
Name of workplace
&
District Name
Joining Date
dd/mm/yyyy
Release
Date
dd/mm/yyyy
Pay Scale
Basic
Pay
(1 , 2 & 3 )
3
4
5
6
7
8
9
Time Scale
st
nd
rd
Date of Time
Scale
dd/mm/yyyy
10
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
1=Regular, 2=Promoted, 3=Deputation (Working), 4=Deputation (Study), 5=OSD, 6=Lien, 7=Study Leave, 8=Transferred
H=Hospital & District Hospital, DDHO= Divisional Director Health Office, CSO=Civil Surgeon Office, NI=Nursing Institute,
UHC=Upazilla Health Complex
Current Service Status (Tick):
Current Charge
Additional Charge
Own Pay
wet `ªt dg© bs 2 G Service Particulars ev PvKzixi wek` weeiYx w`‡Z n‡e| First Service Information G cÖ_g PvKzixi Gc‡q›U‡g›U Gi ZvwiL Ges Gi
wRI bv¤^vi wjL‡Z n‡e|
Service Particulars ‡Uwejt 1 bs Kjv‡g µwgK bv¤^vi w`‡q kyiy Ki‡Z n‡e| 2 bs Kjv‡g (Designation) c`ex Ges c`exi †÷Uvm wjL‡Z n‡e| †Uwe‡ji
†klvs‡k c`exi †÷Uvm †`qv Av‡Q| †gvU 7 wU †÷Uvm i‡q‡Q Zvi g‡a¨ †hUv cÖ‡hvR¨ Zvi bv¤^viwU ïay wjL‡Z n‡e| †hgbt Avcbvi c`ex hw` wmwbqi ÷vd bvm© nq Ges
Avcwb hw` GB c‡` Ab¨ ¯’vb †_‡K e`jx n‡q G‡m _v‡Kb Z‡e GB Kjv‡g wjL‡ebt SSN, 8 Gici 3 bs Kjv‡g Avcbvi Kg©¯’‡ji K¨v‡UMix wjL‡eb| A_©vr, Avcwb
hw` wmwbqi ÷vd bvm© wn‡m‡e †Kvb Dc‡Rjv †nj_ Kg‡c¬· G Kg©iZ _v‡Kb Zvn‡j GB Kjv‡g wjL‡ebt UHC Gici 4bs Kjv‡g D³ Kg©¯’‡ji bvgwU wjL‡Z n‡e
Ges mv‡_ Avcbvi Kg©¯’‡ji †Rjvi bvgwUI wjL‡Z n‡et Kalihati UHC, Tangail cieZ©x 5 Ges 6 bs Kjv‡g Kg©¯’‡j †hvM`v‡bi ZvwiL Ges †mB Kg©¯’j †_‡K
wiwjR ‡bqvi ZvwiL wjL‡Z n‡e| ZvwiL wjLvi wbw`©ó GKwU di‡gU i‡q‡Q hv Kjv‡gi Dc‡i m‡bœ‡ewkZ Av‡Q| ZvwiL ‡jLvi di‡gUwU n‡jvt dd/mm/yyyy A_©vr
w`b-gvm-eQi GB Q‡K ZvwiLwU wjL‡Z n‡e| hw` Avcbvi †hvM`v‡bi ZvwiL nq 1jv b‡f¤^i 1974 Zvn‡j wjL‡Z n‡et 01/11/1974 7 bs Kjv‡g Avcbvi c`ex
Abyhvqx ‡eZb †¯‹jwU wjL‡Z n‡e Ges 8 bs Kjv‡g Avcbvi g~j ‡eZb wjL‡Z n‡e| 9 bs Kjv‡g UvBg †¯‹j †c‡q _vK‡j Zv KZ bv¤^vi UvBg †¯‹j Zv wjL‡Z n‡e| 10
bs Kjv‡g UvBg †¯‹jwU ‡h Zvwi‡L cÖvß n‡q‡Q Zv wjL‡Z n‡e| Service Particulars †Uwe‡j Avcbvi PvKzixi cÖ_g c` n‡Z ïiy K‡i eZ©gv‡b †h c‡` Av‡Qb Zv
µgvbœ‡q wjL‡Z n‡e| eZ©gvb c‡`i †¶‡Î 6 bs KjvgwU Lvwj _vK‡e| ‡Uwe‡ji 15wU †iv Gi †ekx hw` wjL‡Z jv‡M Z‡e mxUwU d‡UvKwc K‡i Zv wWwmwUi †k‡l fvjfv‡e
jvwM‡q w`‡Z n‡e|
4
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)
Data Collection Tool - Form 03
Promotion Information (Ascending order)
Date of Promotion
dd/mm/yyyy
1
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Promoted Post
Workplace
G. O. No.
2
3
4
Pre-Promoted
Pay scale
5
Promoted
Pay scale
6
wet `ªt dg© bs 3 G `ywU †Uwej i‡q‡Q| cÖ_g †Uwe‡j PvKzixi cÖ‡gvkb msµvš— wewea Z_¨ weeibx w`‡Z n‡e| wØZxq †Uwe‡j wj‡qb msµvš— Z_¨ w`‡Z n‡e|
Promotion Information †Uwejt GB †Uwe‡ji 1 bs Kjv‡g cÖ‡gvkb Gi ZvwiL wjL‡Z n‡e| 2 bs Kjv‡g cÖ‡gvkb n‡q †h c‡` wM‡q‡Q Ges 3 bs
Kjv‡g Zvi Kg©¯’‡ji bvg wjL‡Z n‡e| 4 bs Kjv‡g wRI bv¤^vi Ges 5 I 6 bs Kjv‡g h_vµ‡g cÖ‡gvk‡bi c~‡e©i †eZb †¯‹j Ges cieZx© †eZb †¯‹j
wjL‡Z n‡e|
Lien Information (Ascending order)
Date of Lien
dd/mm/yyyy
In-Country
(Place of Lien)
Overseas
(Place & Country)
G.O. No.
1
2
3
4
Release
Date for lien
dd/mm/yyyy
5
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
G.O. No.
6
Lien Information †Uwejt GB †Uwe‡ji 1 bs Kjv‡g wj‡qb Gi ZvwiL wjL‡Z n‡e| wj‡qbwU hw` †`‡ki g‡a¨ nq Zvn‡j 2 bs Kjv‡g ¯’vbwU wjL‡Z
n‡e| hw` wj‡qb †`‡ki evwn‡ii Rb¨ nq Zvn‡j ‡`‡ki bvg mn Ae¯’vb wjL‡Z n‡e 3 bs Kjv‡g| 4 bs Kjv‡g wj‡q‡bi wRI bv¤^vi Ges wj‡q‡bi wiwjR
Gi ZvwiL Ges Zvi wRI bv¤^vi 5 Ges 6 bs Kjv‡g wjL‡Z n‡e|
5
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)
Data Collection Tool - Form 04
Local Training (Ascending order)
Title of Training
Training Institution
1
2
Start Date
dd/mm/yyyy
3
End Date
dd/mm/yyyy
4
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
wet`ªt 4 bs d‡g©I `ywU †Uwej i‡q‡Q| cÖ_g †Uwe‡j Local Training A_©vr Avf¨š —ixb cÖwk¶Y m¤úwK©Z Z_¨ weeiYx w`‡Z n‡e| 1 bs Kjv‡g ‡Uªwbs Gi
UvB‡Uj A_©vr wK †Uªwbs Zv wjL‡Z n‡e| 2 bs Kjv‡g ‡h cÖwZôvb †_‡K †Uªwbs wb‡q‡Q Zv wjL‡Z n‡e| 3 bs Kjv‡g Zvwi‡Li di‡gU Abyhvqx †Uªwbs Gi
Avi‡¤¢i ZvwiL Ges 4 bs Kjv‡g †Uªwbs †kl nIqvi ZvwiL wjL‡Z n‡e|
Foreign Training (Ascending order)
Title of Training
1
Training Institution
2
Start Date
dd/mm/yyyy
3
End Date
dd/mm/yyyy
4
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
/
Country
5
wØZxq †Uwe‡j Foreign Training A_©vr we‡`k cÖwk¶Y m¤úwK©Z Z_¨ weeiYx w`‡Z n‡e| 1 †_‡K 4 bs Kjvg local training ‡Uwej Abyhvqx n‡e ïay
5 bs Kjv‡g †h †`k †_‡K †Uªwbs wb‡q‡Qb Zvi bvg wjL‡Z n‡e|
6
wWwmwU d‡g©i †Kvb welq bv eyS‡j mivmwi †dvb Ki“bt 01716643689 (wWGbGm Gi c‡¶ †gvt gvneyeyi ingvb, AvBwU †¯úkvwjó, GBPAviGBP cÖ‡R± Bb evsjv‡`k)