Position Code: NC-ME-WNTSN State(s) and District(s) in Which Vacancies Exist: Delhi

1. Personal Details:

Applicant's Name:
Father/Husband's Name: Date of Birth:
Gender: Mobile No.:
Email ID: Alternate Contact No.:

2. Address:

Current City of Residence: City of Domicile(State):
Correspondence/ Current Address with Pin Code: Permanent Address with Pin Code

3. Qualification Details:

Name of Degree/Diploma
Specialization & Principal Subjects
Name of University/ Institute (City)
Passing Year
Marks (in %)/ GPA
MCI Registration (Only for Medical Qualifications )

4. Employment Details. (Please start with current/ most recent experience. If you have worked in more than one area/ post within the same organization, please enter details of the same separately):

# Name of Organisation Designation/ Title Key Responsibilities From To Location (City, State)
Current Employment Details:
Other Employment Details:

5. Areas of Specialisation. (Please note that your response to this part of the application form shall be scored and qualitatively assessed to confirm your suitability for the post. We urge you to carefully fill your response and provide adequate details.):

# Name of Organisation Details of Key Job Responsibilities, Duties, Tasks Handled and/or Accomplishments to Demonstrate Relevance of Experience in Requisite Areas Duration of Experience (in months) Location (City, State)
1. Experience in public health programmes/ projects, in handling program surveillance data, or operational research, or monitoring and evaluation, at state or national level:. (Please fill details of your experience in the row below):
2. Experience in provision of technical support in analyzing the programme data and conducting in-depth analysis and interpretation of routine surveillance data:. (Please fill details of your experience in the row below):
3. Experience in defining monitoring and evaluation strategy of the programme and facilitating internal and external evaluation for the programme:. (Please fill details of your experience in the row below):
4. Experience in TB Programmes, highlighting exposure to Nikshay, if any. (Please fill details of your experience in the row below):

6. Present Salary and Allowances in INR lacs per annum. (Please use this section to report your present gross salary):

a. Annual Salary: b. Annual Allowances* if any. (Excluding components already included in a.): c. Gross Annual Salary and Allowances:
*Please exclude travel/ per diems and/or other allowances that comprise reimbursement of expenses incurred by you.

7. Computer Skills:

(1) Proficiency in use of MS Office
a. Excel
b. Word
c. Power Point
(2) Proficiency in use of Statistical Software
a. Epi-info
c. Other Statistical Software (please provide details and confirm proficiency)

8. Language Proficiency:

Language Read Write Speak

9. Location Preferences:

Available Locations Location Preference
Add Preference
Remove Preference

  • (1) Applicants are required to provide a minimum of 1 location preferences for this position. Please note that without providing 1 location preferences, the applicant shall not be able to proceed further and submit the application;
  • (2) Applicants must clearly indicate preference in respect of all locations identified;
  • (3) Applicants can select location preference from 'Available Location Box' by clicking on button. Similarly, Applicants can change the preference of location by clicking
  • Location preference marked by you does not guarantee allotment of a preferred location. Final allotment shall depend on the decision of the Selection Committee.
Ability and willingness to travel extensively (30%), based on the needs of the job. Joining Time (in days):

10. Referees. (Please list three supervisors to whom you have reported professionally in the recent past, whom we can immediately contact for reference checking. Please note that reference checking shall only be initiated in case the applicant has been found suitable pursuant to final interview ):

# Name Address Email Phone Organization Designation Your Professional Relationship With and Year of Reporting to Referee

11. Upload CV:

Certification: I certify that to the best of my knowledge and belief, the details submitted by me correctly describe my qualification, experience and other information, as requested by SAMS.