Version: 1.
13, Date: 05 Dec 2016
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Directorate General of Nursing & Midwifery
Data Collection Tool Photo
Place of posting:_______________________________________ District:____________________
General Information
BNC Registration No.: National ID No.:
Personal Information
Full Name (English) Name (Bangla)
(Capital Letter)
Sex (Tick) Male Female Passport Number
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, Se=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
Present Permanent
Village/House/Road
Division
District
Thana/Upazilla
Post Office
Postal Code
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1
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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
First Issue Date Last Renewal Date
Type of Registration (Please tick your desired option) Reg. Number
dd/mm/yyyy 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 G.O. No. of
0 8 1 2 2 0 1 6
Appointment 45.158.011.00.00.023.2016-508
(Day) (Month) (Year)
G.O. No. of
Date of Joining Joining
1 5 1 2 2 0 1 6
(Day) (Month) (Year)
Designation Workplace Name of workplace &
Pay Scale Basic Pay
Category** District Name
1 2 3 4 5
SSN= Senior Staff Nurse 16000-38000
16000
(Grade-10)
**Workplace MCH=Medical College Hospital, MI=Medical Institute, H=Hospital & District Hospital, DC= Dental College, DDHO= Divisional
Category 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
Signature of Employee Date: 15 December 2016
2
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