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Version: 1.13, Date: 05 Dec 2016

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Directorate General of Nursing & Midwifery Data Collection Tool Place of posting: District:
Directorate General of Nursing & Midwifery
Data Collection Tool
Place of posting:
District:

Photo

General Information

BNC Registration No.:

District: Photo General Information BNC Registration No.: National ID No.: Personal Information Full Name (English)

National ID No.:

General Information BNC Registration No.: National ID No.: Personal Information Full Name (English) (Capital Letter)

Personal Information

Full Name (English)

(Capital Letter)

Sex (Tick)

Male

FemaleFull Name (English) (Capital Letter) Sex (Tick) Male Name (Bangla) Passport Number Father’s Name Mother’s

Full Name (English) (Capital Letter) Sex (Tick) Male Female Name (Bangla) Passport Number Father’s Name Mother’s

Name (Bangla)

Passport Number

Letter) Sex (Tick) Male Female Name (Bangla) Passport Number Father’s Name Mother’s Name Date of Birth
Father’s Name Mother’s Name Date of Birth Birth Place (District) (Day) (Month) (Year) Marital Status
Father’s Name
Mother’s Name
Date of Birth
Birth Place (District)
(Day)
(Month)
(Year)
Marital Status (Tick)
S
M
W
D
Se
Religion (Tick)
I
Hi
Bu
Ch
O
S =Single, M =Married, W =Widow, D=Divorced, S e=Separated
I=Islam, Hi =Hindu, Bu =Buddhist, Ch =Christian, O =Others
Mobile Number
E-mail Address
Official Information
BPSC Merit No./Sl No
BPSC registration No:
Specialty posting:

e.g.: ICU/ CCU/ Cardiovascular/ Child/ Psychiatric nursing ect.

Mailing Addresses

Village/House/Road

Division

District

Thana/Upazilla

Post Office

Postal Code

Present

Permanent

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General Educational Qualification

 

Level of Education (Please tick your desired option)

Board

Division/CGPA

Year

Country

1

2

3

4

5

SSC/ O Level/ Dakhil/ Equivalent

       

HSC/ A Level/ Alim/ Equivalent

       

Professional Educational Qualification

 

Level of Education (Please tick your desired option)

Institute/College/University

Division/Class/CGPA

Year

Country

Diploma in Nursing/ Midwifery/ Orthopedic

       

If others, specify:

B.Sc in Nursing (Basic)/ B.Sc in Nursing (Post- Basic)/ B.Sc in Nursing/ Public Health Nursing

       

Masters if any, please specify:

       

BNMC Registration Information

 

Type of Registration (Please tick your desired option)

Reg. Number

First Issue Date dd/mm/yyyy

Last Renewal Date dd/mm/yyyy

Diploma in Nursing / Diploma in Nursing Science & Midwifery

 

/ /

/ /

Diploma in Midwifery

 

/ /

/ /

B.Sc in Nursing (Basic)

 

/ /

/ /

B.Sc in Nursing/Public Health Nursing

 

/ /

/ /

Specialty (Specify):

 

/ /

/ /

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Service Particulars

Date of Appointment

Date of Joining

0 8 1 2 2 0 1 6 (Day) (Month) (Year)
0
8
1 2
2 0
1 6
(Day)
(Month)
(Year)
1 5 1 2 2 0 1 6 (Day) (Month) (Year)
1
5
1 2
2 0
1 6
(Day)
(Month)
(Year)

G.O. No. of Appointment

45.158.011.00.00.023.2016-508

G.O. No. of

Joining

Designation

Workplace

Name of workplace & District Name

   

Category**

Pay Scale

Basic Pay

1

2

3

4

5

SSN= Senior Staff Nurse

   

16000-38000

 

(Grade-10)

16000

**Workplace

MCH=Medical College Hospital, MI=Medical Institute, H=Hospital & District Hospital, DC= Dental College, DDHO= Divisional Director Health Office, CSO=Civil Surgeon Office, CDC=Chest Diseases Clinic, NI=Nursing Institute, NI=Nursing College, MFPC= Model Family Planning Clinic, UHC=Upazilla Health Complex, RHC= Rural Health Complex, USC=Union Sub Center

Category

Signature of Employee

Date: 15 December 2016

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