FORM OF MEDICAL REIMURSEMENT CLAIM

Form of application and claming refund of medical expenses incurred in connection with medical
attendance and treatment of central government servants and their families. N. B. Separate’s forms should
be used for each patient and cases.

1. Name & Designation of Govt. Servant (in Block letters) _______________________________

2. Whether married. if married, the place where wife/husband _____________________________
is employed
3. Office in which employed. _____________________________________________
4.pay of the Govt. servant as defined in the fundamental rules & __________________________
any other emoluments which should be shown separately . __________________________
5. Actual residential address ___________________________

6. Place of duty. __________________________

7. Name of the patient and his/her relationship with the Govt. __________________________
servant NB : In cash of children state age also place when patient fall ill. ____________________
8. Nature of illness claimed. _________________________________________________
9. Details of the amount claimed: _________________________________________________
i) Fee for consultation indicating: _________________________________________________
ii) The name & designation of the medical officer consulted & the hospital or
dispensary to which attached. _________________________________________________
iii) the number and dates of injection & the fee paid for each injection. ______________________
iv) the number and dates of consultation & has fee paid for each consultation. ________________
v) Whether consultation and injections were had at hospital/army consulting._________________
room of the medical officer or at the residence of the patient. _____________________
10. Any other charges. ________________________________________
11. Cost of medicines cash memo & the consentially certificate should be attached. ____________
12. Total amount claimed Rs. _______________________
13. Net amount claimed Rs. ________________________
14. List of enclosures: _____________________________

DECLARATION TO BE SIGNED BY THE GOVERMENT SERVANT

I hereby declare that the statement in the application are true to the best of my knowledge and belief and the person
for whom medical expenditure incurred is wholly depend upon etc

Date :
Signature of the Govt. servant
& Designation :
 ESSENTIALITY CERTIFICATES
CERTIFICATE (A)

Certificate granted to Mrs./Mr./Miss………………………………………………… Wife/son/daughter of

Mr……………………………………… employed in the …………………………………….

I, Dr……………………………………………hereby certify.
(a) that I charged and received Rs…………………………….for consultations on
…………………………….(dated to be given) at my consulting room/a the resident of the patient.
(b) that I charged and received Rs. ………………for administering
……………………………………………….. in the venous, intramuscular subcutaneous injections
on……………………………….(date to be given ) at…………… my consulting room the residence of the
patient.
(c) That the injections administered were not /were for immunizing or prophylactic purposes.
(d) That the patient has been under treatment at………………….hospital/ my consulting room and that the
under mentioned medicines prescribed by me in this connection were essential for the recovery / prevention
of serious deterioration in the condition of the patient. The medicines are not stocked in
the……………………….(name of hospital) for supply to private patients and do not included proprietary
preparations for which cheaper substances of equal the apeutic value are available nor preparations which
are primarily foods, toilets or disinfectants.
Sl No. Name of medicines Qty. Prices

That the patient is/was suffering from…………………… and is/was under my treatment
from………………………………………to……………………………. (e) that the patient is/was not given
pre-natal or post-natal treatment.
(f) That the Xray laboratory test etc. for which an expenditure of Rs…………
……………………………….name of the hospital or laboratory.
(g) that I referred the patient to Dr……………………….for specialist consultation and that the necessary
approval of the ……………………..(name of the Chief Administrative Officer of the State ) as required
under the rules was obtained.
(h) That the patient did not required hospitalisation.

Signature & Designation of the Medical Officer and

Hospital Dispensary to which attached
 CERTIFICATE ‘B’
(To be completed in the case of patients who are admitted to hospital for
Treatment
Certificate granted to Mrs. / Mr. Miss______________________________wife/son/daughter of Mr.
/Mrs._______________________________Employed in the_________________________

PART ‘A’

I, Dr _______________________________hereby certify:-
(a) That the patient was admitted to hospital on the advice of_______________ (Name of the medical officer / on my
advice:
(b) That the patient has been under treatment at ______________ and that the under mentioned medicines prescribed
by me in this connection were essential for the recovery / prevention of serious deterioration in the condition of the
patient. The medicines are not stocked in the_________________________ (Name of the hospital) for supply to
private patients and do ot include proprietary preparations for which cheaper substances of equal therapeutic value are
available not preparations which are primarily foods, toilets or disinfectants:
Name of medicines Price
1.__________________________ 5________________________
2. __________________________ 6________________________
3. __________________________ 7________________________
4. ___________________________ 8________________________
(c) That the injections administered were/were not for immunizing or prophylactic purposes:
(d) That the patient, is/was suffering from ____________________ and is / was under treatment from
__________________-to ___________________
(e) That the X-ray, laboratory tests etc. for which an expenditure of Rs_________________ was incurred were
necessary and were taken (under) on my advice at_____________________________________(name of hospital or
laboratory).
(f) That I called on Dr______________________________ for specialist consultation and that the necessary approval
of the (Name of the Chief Administrative medical Officer of the State as required under the rules, was obtained.

Signature and Designation Of the medical Officer

In- charge of the case at The hospital

PART ‘B’

I certify that the patient has been under treatment at the ___________________ hospital and that the service of the
special nurses for which an expenditure of Rs________________________ was incurred, vide bills and receipts
attached, were essential for the recovery/prevention of serious deterioration in the condition of the patient.

Signature of the medical Officer

In- charge of the Case at the hospital.

COUNTERSIGNED
Certify that the patient has been under treatment at the _____________ hospital and that the
facilities provided were the minimum which were essential for the patient’s treatment.

Medical Superintendent.
Place:__________________. ____________Hospital.
 GOVERNMENT OF N.C.T. OF DELHI
AMBEDKAR INSTITUTE OF TECHNOLOGY
GEETA COLONY, DELHI-110031.

Statement of immovable property on first appointment for the year 2007-2008

1. Name of Officer ( in full) and the

Service to which the officer belongs :
2. Present post held :
3. Present Pay :
4. Details of Properties :

Name of Distt. Sub-

Division, Taluk &
Village in which Name & details of Property
property is situated
Housing & Lands Present Value
Other (in Rs.)
Buildings
1 2 3 4

If not in own name How acquired Annual Remarks

State in whose name By purchase, lease , income from
held and his/her mortgage, inheritance, gift the property
relationship to Govt. or otherwise with date of
servant acquisition and name with
details of persons from
whom acquired
5 6 7 8

Name & Signature of the Officer

Date:
 UNDERTAKIG

I,…………………………..S/o/D/o Shri…………………………….R/o
…………………………………………………………….., who has been appointed on purely
contract basis to the post of ………………………………………..by Dte. Of Training and
Technical Education, GNCT of Delhi and posted in AIT with terms and conditions mentioned in
letter No.F.5(93)/2007-SB/ dated 6.2.2008 is hereby undertake that I will not file any Court
case during or after this contract period for seeking any regular appointment and follow all the terms
and conditions contained in the said acceptance letter.

I hereby further undertake that I will submit certificate of medical from registered MBBS
doctor and verified/submitted original educational degree/certificate latest by 15.2.2008 failing
which I will be fully liable for cancellation of above said appointment.

Signature
Name & Designation
Contact No.
Date:

Copy to:
1. Principal, AIT, Shakarpur.
2. Dy. Director (SB), Dte. Of Training and Technical Education, GNCT of Delhi, Muni Maya Ram
Marg, Pitampura, Delhi-110088 with reference to his letter No.F.5(93)/2007-SB/ dated 6.2.2008
 GOVERNMENT OF N.C.T. OF DELHI
AMBEDKAR INSTITUTE OF TECHNOLOGY
GEETA COLONY, DELHI-110031.

Statement of immovable property on first appointment for the year 2007-2008

4. Name of Officer ( in full) and the

Service to which the officer belongs :
5. Present post held :
6. Present Pay :
4. Details of Properties :

Name of Distt. Sub-

Division, Taluk &
Village in which Name & details of Property
property is situated
Housing & Lands Present Value
Other (in Rs.)
Buildings
1 2 3 4

If not in own name How acquired Annual Remarks

State in whose name By purchase, lease , income from
held and his/her mortgage, inheritance, gift the property
relationship to Govt. or otherwise with date of
servant acquisition and name with
details of persons from
whom acquired
5 6 7 8

Name & Signature of the Officer

Date
 PROFORMA FOR GRANT OF ACP BENEFITS

1 Name of the official

2 Date of Birth

2(a) Category (SC/ST/PH/GEN.)

3 Date of initial appointment with Post and pay scale

4 Mode of Recruitment (SSC/Compassionate/

Redeployed/Absorption/Promotion) and
Date of entry in service in Govt. of Delhi

5 Date of first Regular promotion

(Including in-situ promotion) with
Post and Pay scale

6 Seniority No. in Gr-I, II, III & IV (DASS)

Seniority No. in Gr-I, II & III (Steno)

7 Date on which the official is completing 10/20/30 years

of Regular service

8. Whether the official was/is under Suspension/Departmental

/Vigilance Case being contemplated / pending. If so, attach a
brief note and copy of Charge-Sheet.

9. Whether any penalty was/ is imposed on the official. If so,

details thereof along-with a copy of relevant order.

10 E.O.L. on private affairs, if any

11 Whether Integrity Certified (Yes/NO)

12 Type test report (passed/exempted), along with relevant

opy of order, If exempted date w.e.f. exemption granted.

13 ACRs enclosed for the years

14 Other details, if any, relevant as per the ACP Scheme.

Certified that the above particulars are taken from the Service Book of the official
concerned.

(Signature of the Competent Authority) with seal

 AMBEDKAR INSTITUTE OF TECHNOLOGY
GOVT. OF NCT OF DELHI
GEETA COLONY: DELHI-31

APPLICATION FOR AN ADVANCE FOR AWAILING LTC (HOME TOWN)/ALL INIDA FOR
THE BLOCK YEAR…………………….

1. Name & designation :

2. Basic pay :

3. Full address of home town :

as per service record

4. Nearest railway station :

5. Block year applied for LTC

Home town requires

6. Period and nature of leave :

7. Detail of family members for LTC advance:

S.NO. NAME OF THE FAMILY MEMBER AGE SEX RELATIONSHIP

8. No. of tickets for onward journey………………and inward journey…………

9. …………..class rail fare from Delhi to …………………………….. and back. The total rail fare
Rs………….., road mileage covered in kms………………….
10. The total bus fare rs………….., road mileage covered in kms……………. from ………………….. to
…………………………… and back.
11. Total fare (s.no.9 and 10) rs…………………(rupees ………………………………………
12. Amount of advance required (i.e. 90% of total fare (S.No.11) Rs……………………. .

Certified that the LTC has not been availed be me and family members earlier against the above mentioned
Block Year i.e. ………………………….

Dated: (Signature of officer/official)

REGISTERED A.D.
 GOVERNMENT OF N.C.T. OF DELHI
AMBEDKAR INSTITUTE OF TECHNOLOGY
GEETA COLONY, DELHI-110031.

No. F.4(38)Security/Sanitation/AIT/2008/ Dated.

To
M/s ……………………………..
………………………………….
………………………………….
………………………………….

Sub: - Return of EMD.

Madam/Sir,

Please find enclosed herewith the EMD submitted in this Institute with reference to Tender No. 033-
2008-00168/69. The detail is given below:-

Draft/Cheque No Date Name of Bank Amount

Kindly acknowledge the receipt.

Yours faithfully

ADMINISTRATIVE OFFICER, AIT

 APPLICATION FORM DISPENSARY

1. Name of Govt. Servant:___________________________________________

2. Designation:____________________________________________________

3. Date of Birth:____________________________________________________

4. Date of Superannuation: _________________________________________

5. Basic Pay:________________________________________________________

6. Residential Address:________________________________________________

7. Opted Delhi Govt. Dispensary:_______________________________________

8. Detail of family (Dependents as per CSMA):

S.No Name D.O.B Relation ship Occupation

Certified that the information furnished above is correct and true best of my knowledge

(Signature of Applicants)

Verified from Admn. Branch._________

Account Branch________
 GOVT. OF NATIONAL CAPITAL TERRITORY OF DELHI
AMBEDKAR INSTITUTE OF TECHNOLOGY
GEETA COLONY – 110031

Form of Confidential Report for the post of Professor/Asstt. Professor/Lecturers/ Lecturers (Senior
Scale/ Selection Grade)

Name of the Faculty____

Report for the year/period ending from :

 GOVT. OF NATIONAL CAPITAL TERRITORY OF DELHI
AMBEDKAR INSTITUTE OF TECHNOLOGY
GEETA COLONY – 110031

Form of Confidential Report for the post of Professor

Department / Office of Electronics & Communication Deptt.

Ambedkar Institute of Technology.

Report for the year/period ending-

Part I – Personal Data

(To be filled by the Administrative Section concerned of the Department/ Office)
1. Name of the Faculty :
2. Designation :
3. Date of Birth :
4. Academic Qualifications :
5. Whether the officer :
belongs to Scheduled
Caste / Scheduled Tribe
6. Date of continuous Date: Grade:
appointment to the
present grade

Part II – SELF APPRAISAL

(To be filled in the officer reported upon)
(Please read carefully the instructions given at the end of the form before filling the entries)
Brief description of duties :

i) Courses taught at various levels: (Name the courses)

Total lectures Total lectures Reasons for not

Scheduled actually engaged engaging the
remaining
classes, if any

a) Under Graduate:

b) Post Graduate:

c) Total of hours / periods provided in the time table for lect. Tute., Practical, Seminars/Discussions in
 the academic year and the number actually taken during the year.

iii) Work load per week:

a) Lectures:
b) Tutorials:
c) Practicals:
d) Seminars/Group Discussions: as required
3. Details of teaching methods employed by you
(Lectures, Tutorials, Seminars, Practicals etc.)
Black Board teaching , Power Point Presentations,
Lecture notes , Assignments& Tutorials ,
Group discussions, Questionnaires &
One to one interaction etc.

4.a) Details of Tutorials/ tests held during the academic year

Under-graduate Post-Graduate
Courses Courses
_______________ ________________

Number of tests held

In each semester there are two phase tests and one end semester exam.

Please give the details

Semester wise & course wise

Assignment checked
Indicate time taken for submission

b) Details of academic planning / presentation of lectures during the session : Preparation of

lecture presentation on power point/slides as per schedule & lession plan of all the theory and
practical work .
c) Please give specific details- To prepare power point presentations as per plan and execute the same
topic wise .Starting of next lecture will be with review of the previous one.

PART III – RESEARCH & DEVELOPMENT, CONTINUING EDUCATION AND

INTERACTION WITH THE INDUSTRIES & PROFESSIONAL SOCIETIES

1 a) Details of published / research papers in reputed journals, books monographs, reviews chapter in
books, translations & creative writing etc. If any during period under review.
 b) Details of editing learned journals and proceedings:

2 Participation in Conferences, Seminars, Workshops:

Give details of the papers presented and / or officials position held.
Conferences National / International :

3. Summer Institutes, refresher or orientation courses attended or conducted. Give details.

Details of U.G. and P. G. Project Guidance:

Ph. D. Guidance:

Sponsored Research Guidance-

5 Details of Industrial Interaction / professional consultancy / patent obtained or applied for:
7 Membership or fellowship of professional / academic Bodies, Societies etc. give details: Any other
information regarding academic activities not covered:
 Part – IV : CONTRIBUTION TO INSTITUTE CORPORATE LIFE

(Details of your contribution to the Corporate Life of the Institution should be specified with Initiatives
taken and achievements made)

1. a) Curriculum development:

Give the details of Courses developed / revised:

2. Laboratory Development and experimental set up:

Give the details of Preparation of Laboratory manual design of new experimental set up and new
facility added during the year.

3a) Cultural / extra curricular activity:

b) Sports / Community and Extension services / N. S. S.:

c) Administrative Assignment:.

d) Any Other-

I certify that the information given above are correct and factual to the best of my knowledge.

Signature ______________________________

Name -

Department _Electronics & Communication Departme

Dated:

Name of the Officer Period

 PART V – ASSESSMENT OF THE REPORTING OFFICER

1. Has the officer show himself

able to do the work of his
appointment.

2. Conduct

3. Regularity and Punctuality

4. Trustworthiness

5. Zeal

6. Performances of duties

7 a) Knowledge of the branch on

which engaged and quality of work

b) Ability to manage the class

and maintain discipline
among the students

8. Has the officer published any

original papers or conducted any
research during the year under
report or otherwise in any manner
done distinguished work.

9. Fitness for promotion to the higher

grade and for further advancement.

10. General assessment taking all the

above points into consideration
(of personality, integrity and
temperament including relations
with fellow members of staff.
11. Grading (Outstanding / Very Good /
Good / Average / Below Average)

(An officer should not be graded outstanding unless exceptional qualities and performance have been
noticed ; grounds for giving such a grading should be clearly brought out

Signature of the Reporting Officer:

Place : Name in Block Letters :

Date: Designation :
(during the period of report)

Part VI – REMARKS OF THE REVIEWING OFFICER

1. Length of service under the Reviewing Officer

2. Is the Reviewing Officer satisfied that the Reporting Officer has made his / her report with due care
and attention and after taking into account all the relevant material?

3. Do you agree with the assessment of the officer given by the Reporting Officer?
(In case of disagreement, please specify the reasons). Is anything you wish to modify or add?

4. General Remarks with specific comments about the general remarks given by the Reporting Officer
and remarks about the meritorious work of the officer including the grading.

5. Has the officer any specific characteristics, and / or any abilities which would justify his / her
selection for special assignment or /out – of – turn promotion?

Signature of the Reviewing Officer:

Place : Name in Block Letters :

Date: Designation:
 INSTRUCTIONS

(To be read carefully before filling the entries in the Confidential Repot Forms)

1. The Confidential Report is an important document. It provides the basic and vital inputs for
assessing the performance of an offcer and for his / her further advancement in his / her career. The
officer reported upon the Reporting Officer and the Reviewing Officer should therefore, undertake
the duty of filling out the form with it high sense of responsibility.

2. Performance appraisal through confidential reports should be used as a tool for human resources
development. Reporting Officers should realize that the objectives is to develop an officer so that
he / she realizes his / her true potential. It is not meant to be fault – finding process but a
development one. The Reporting Officer and the Reviewing Officer should not shy away from
reporting shortcomings in performance, attitudes or overall personality of the officer reported upon.

3. The items should be filled with due care and attention and after devoting adequate time. Any attempt
to fill the report in a casual or superficial manner will be easily discernible to the higher authorities.

4. If the Reviewing Officer is satisfied that the Reporting Officer had made the report without due care
and attention he / she shall record a mark to that effect in item 2 of Part – V. The Government shall
enter the remarks in the confidential roll of the Reporting Officer.

5. Every answer shall be given in a narrative form. The space provided indicates the desired length of
the answer. Words and phrases should be chosen carefully and should accurately reflect the
intention of the officer recording the answer. Please use unambiguous and simple language. Please
do not use omnibus expressions like ‘outstanding’, ‘very good’, ‘good’, ‘average’, ‘below average’
while giving your comments against any of the attributes.

6. The Reporting Officer shall in the beginning of the year, assign targets to each of the officers with
respect to whom he is required to report upon for completion during the year. In the case of an
officer taking up a new post in the course of the reporting year, such targets / goals shall be set at the
time of assumption of the new charge. The targets set should clearly be known and understood by
both the officers concerned