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Name of Centre/Hospital/Institution Name:
Address:
City, State, Pincode:
Centre Head (Name & Designation):
Contact Phone:
Email:
Please list all core faculty involved in the fellowship training program (add rows if needed):
Faculty Name
Designation & Specialty
FIAPM Qualified
Year FIAPM Awarded
YesNo
(All core faculty must be FIAPM-qualified pain physicians, with a minimum of 2 years post-FIAPM experience.)
Number of Fellowship Positions applied (per year):
Number of Additional Fellowship positions applied (per year):
*(Applicable for centres applying for additional seats)
Current Approved FIAPM Fellowship Position(per year):
Other Pain Fellows/Observers (Non-FIAPM):
Stipend for Fellow (per month): ₹(INR):
Please indicate whether the centre meets the following key requirements:
Multidisciplinary Faculty: Centre has practitioners from at least two medical specialties on the pain team (including at least one FIAPM-qualified pain physician).
Yes No
Allied Specialist Support: Centre has allied health professionals in pain management.
Outpatient Pain Clinic: Regular chronic pain outpatient clinics are conducted.
Frequency:
Procedure Facilities: Dedicated pain procedure room/operating theatre is available for interventions.
Post-procedure Care: A recovery/observation area with monitoring is available for post-procedure care.
Inpatient/Day-Care Access: The centre can admit pain patients for inpatient or day-care management if required.
Teaching Program: Regular academic activities for fellows (lectures, case conferences, journal clubs) are conducted.
Educational Resources: Fellows have access to learning resources (medical library, pain journals, internet access).
Please attach supporting documents: case logs, lists of equipment, team CVs, etc., as evidence of the above criteria.
Upload Supporting Documents:
Please fill in the number of procedures performed in each category and attach logs where possible. Where minimum volumes are not met, specify how fellows are offered structured exposure through affiliated centres or supervised rotations.
Category (MIPSI)
Description
Actual Annual Volume (Last 12 mo.)
If not available: Exposure Plan for Fellows
Outpatient Load
Total Pain OPD consultations (new + follow-up)
Mandatory in the centre
MIPSI A: Joint/Musculoskeletal Interventions
Major, intermediate & minor joint injections (e.g. facet, SI, knee, shoulder),
bursa/tendon injections, joint denervations, arthrograms
MIPSI B: Nerve Blocks & RFA
Peripheral nerve blocks (e.g. occipital, suprascapular, intercostal),
sympathetic plexus blocks/neurolysis (stellate, celiac, etc.),
Radiofrequency ablations (pulsed or thermal)
MIPSI C: Epidural Procedures
Epidural interventions (interlaminar, transforaminal, caudal),
Adhesiolysis (epidural neuroplasty via catheter, mechanical or chemical)
D: Vertebral Augmentation
Vertebroplasty, Kyphoplasty, Sacroplasty
E: Neuromodulation (SCS/DRG)
Spinal Cord Stimulator trials/implants,
Dorsal Root Ganglion stimulation,
Peripheral nerve stimulation
F: Intrathecal Therapies
Intrathecal pump implants/trials,
neurolytic blocks, port placements
G: Intradiscal Procedures
Discography, Ozone nucleolysis,
Nucleoplasty, Annuloplasty, IDET, Biacuplasty
H: Endoscopic Pain Procedures (MisEpp)
Endoscopic discectomy,
decompression, rhizotomy
I: Regenerative Interventions ("Pain Biologics")
PRP, stem cell treatments for pain
J: Other Therapies
e.g., Botulinum toxin,
Acupuncture, Shockwave, TENS
Note: Where a category is not available in-house, attach documentation of a formal MOU/rotation plan ensuring fellows receive supervised exposure.
I, Dr. , Head of , hereby certify that this centre complies with all the revised FIAPM training accreditation criteria (Version 2026).
All information provided is true and accurate. I understand false information may lead to disqualification.
I am willing to produce documentary evidence at inspection.
Place:
Date:
Centre Head’s Signature:
Name:
Designation:
Submission: Please submit this completed form, with all required enclosures, to the Registrar, Indian Academy of Pain Medicine (IAPM) as per the instructions on the IAPM website or accreditation notification.
