NATIONAL CENTRE FOR DISEASE INFORMATICS AND RESEARCH
(Indian Council of Medical Research)
POPULATION BASED STROKE REGISTRY (PBSR)
Registration Form to be Completed by Potential Participating Centres / Individuals
 * - Indicates Mandatory Fields
1. Name of the Institute / Health Care Facility *
  Postal Address
  Area / Locality
  State *
  District
  City
  Pincode *
  Telephone
  Fax
  Email *  
2. Would you be willing to participate  
3. Principal Investigator *
  Co-Principal Investigator
  Faculty in Charge (If Applicable)
  Name of Co-workers who are willing to participate
4. Brief profile of the Institution
 
Year 2010 2011 2012
Number of  In-Patient Beds
Total Out-Patient Attendance
Total Registrations
Total Proved Cases of Stroke*
*This item has to be completed. Only then your registration form can be further processed.
    
5. Is there in-house Department of Radiology / Imaging?  
  If no, is imaging available outside for your patients  
  If yes in either question, please fill the section below. if no to both, go to item 6.
 
Number of CT scans / MRI done during the year 2012: Total Stroke
CT-Head
MRI-Brain-Head
Total
      
6. Number of stroke patients treated in yourinsitution during the year 2012 at Department of
  Neurology
  Neurosurgery (SAH,ICH)
  Medicine
  Others
7. One critical and important item of patient information for patients diagnosed with stroke is the correct, complete and detailed permanent residential address with duration of stay (or living) in that address. This needs to be gathered directly from the patient or patient's representative. When can you obtain this information?
 
i
ii
iii
iv
v
vi
vii
viii
8.1 Maintenance of Medical Records
      
8.2 If you keep records for all visits, specify wheather each visit has a different number or the same number    
8.3 Are medical records in the form of    
9. Existing Computer facilities - Overall: Please elaborate
  Hardware- Number of servers, desktops, laptops, etc with salient configuration
  Software- Platforms, uses, etc
  Internet Connectivity      
 
10. Would your Institute / Department be able to obtain the following or funds for the following items, for use in the project
 
Available Required
Fund
Yes No
i Personal Computer
ii Independent Telephone Connection
iii Internet/ e-mails Connection
iv Contigency / maintenance
v Data Collection / Entry etc
Total
11. Would your institution be able to collect data and start transmission to NCDIR for all cases of stroke registered / diagnosed / treated from 1 January 2013?    
12. Any other relavant information
  Name
  Principal Investigator
  Designation
13. Remarks
  The hard copy of the above form complete in all respects may be sent to:
  Office of the National Centre for Disease Informatics and Research
Nirmal Bhavan -  ICMR Complex (II Floor), Poojanhalli Road, Off NH-7, Adjecent to Trumpet flyoverof BIAL, Kannamangala Post, Bangalore-562110, Tel: 91 94490 67643, 91 94490 33748, 90 80 28467643; Fax: 91 80 28467644, Email: stroke@ncdirindia.org, ncdir@ncdirindia.org
 
 
  
 * - Indicates Mandatory Fields