APPLICATION FORM FOR ACCREDITATION

Indian Academy of Pain Medicine (IAPM)

(Academic & Training Wing of ISSP)

APPLICATION FORM FOR ACCREDITATION

MisEpp (Minimally Invasive Spine Endoscopic Pain Procedures) Observership Program

SECTION 1: INSTITUTION DETAILS

SECTION 2: FACULTY DETAILS

SECTION 3: ELIGIBILITY DECLARATION

3.1 Faculty Eligibility
Criteria Yes ☐ No ☐

3.2 Institutional Experience
Criteria Yes ☐ No ☐

3.3 Case Volume Requirement
Criteria Yes ☐ No ☐

3.4 Infrastructure & Compliance
Criteria Yes ☐ No ☐

SECTION 4: OBSERVERSHIP PROGRAM DETAILS

SECTION 5: DECLARATION BY INSTITUTION

We hereby declare that:

  1. All the information provided above is true and correct.
  2. Our institution fulfills all the criteria as per IAPM/ISSP guidelines for MisEpp Observership Accreditation.
  3. We understand that:
    • Observership does not confer certification or procedural rights.
    • Observers will not perform independent procedures.
  4. We agree to:
    • Maintain proper documentation.
    • Allow inspection/review by IAPM.
    • Adhere strictly to ethical and clinical standards.

SECTION 6: UNDERTAKING

We undertake to conduct the Observership Program strictly as per the guidelines laid down by IAPM/ISSP and ensure patient safety, ethical conduct, and academic integrity at all times.

 
 

SECTION 7 : SIGNATURES