persons with disabilities form

Upload: vikas-chahal

Post on 30-May-2018

217 views

Category:

Documents


0 download

TRANSCRIPT

  • 8/9/2019 Persons with disabilities form

    1/2

    CERTIFICATE FOR THE PERSONS WITH DISABILITIES

    NAME & ADDRESS OF THE INSTITUTE/HOSPITAL (Issuing Certificate) with seal

    Certificate No.... Date.

    DISABILITY CERTIFICATE

    1)1)1)1) I, Dr...... Reg. No. examined that Shri/Smt./Kum.

    ... Son/wife/daughter of Shri

    ..... Age... Sex Identification mark(s)

    ............. is suffering from permanent disability of following category:-

    A. Loco motor or cerebral palsy:

    1) BL-Both legs affected but not arms

    2) BA-Both arms affected a) Impaired reach

    b) Weakness of grip

    3) BLA-Both legs & both arms affected

    4) OL-One leg affected (Right or Left) a) Impaired reach

    b) Weakness of grip

    c) Ataxic

    5) OA-One arm affected a) Impaired reach

    b) Weakness of grip

    c) Ataxic

    6) BH-Stiff back & hips (cant sit or stoop)

    7) MW-Muscular weakness & limited physical endurance

    B. Blindness or Low Vision: a) B-Blind

    b) PB-Partially Blind

    C. Hearing Impairment: a) D-Deaf

    b) PD-Partially Deaf

    (DELETE THE CATEGORY WHICHEVER IS NOT APPLICABLE)

    2)2)2)2) This condition is progressive/ non-progressive/ likely to improve/ not likely to improve. Re-assessment of this case is not

    recommended/ is recommended after a period of ....... years/ months.

    3)3)3)3) Percentage of disability in his/ her case is ...............................................................................................

    Percent (... %)

    4)4)4)4) Sh./Smt./Kum. .. meets the following

    physical requirements for discharge of his/her duties:-

    F-can perform work by manipulating with fingers. Yes No

    PP-can perform work by pulling & pushing. Yes No

    L-can perform work by lifting. Yes No

    KC-can perform work by kneeling & crouching. Yes No

    B-can perform work by bending. Yes No

    S-can perform work by sitting. Yes No

    ST-can perform work by standing. Yes No

    W-can perform work by walking. Yes No

    SE-can perform work by seeing. Yes No

    H-can perform work by hearing/speaking Yes No

    RW-can perform work by reading & writing. Yes No Signature of Candidate

    Signature of Doctor Signature of Doctor Signature of Doctor

    Name : . Name : . Name :Reg. NO. .. Reg. No. .. Reg. No..

    Member, Medical Board Member, Medical Board Chairperson, Medical Board

    Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)

    * *Note: - The d isabi l i ty cert i f icate should be issued by a Govt . Hospi ta l

    Affix here recent

    attested photographshowing the disability

    duly attested by theMedical Board

    Chairperson

    Affix here recent

    attested photograph

    showing the

    disability duly

    attested by the

    Medical Board

    Chairperson

  • 8/9/2019 Persons with disabilities form

    2/2

    fu%kDrfu%kDrfu%kDrfu%kDr(fodykaxfodykaxfodykaxfodykax) O;fDr;ksa ds fy, izek.k i=O;fDr;ksa ds fy, izek.k i=O;fDr;ksa ds fy, izek.k i=O;fDr;ksa ds fy, izek.k i=

    tkjh djus okys vLirkytkjh djus okys vLirkytkjh djus okys vLirkytkjh djus okys vLirky/ laLFkk dk uki vkSj irklaLFkk dk uki vkSj irklaLFkk dk uki vkSj irklaLFkk dk uki vkSj irk(eksgj ds lkFkeksgj ds lkFkeksgj ds lkFkeksgj ds lkFk)

    izek.k i= la[;k frfFk

    (fodykaxrk izek.k i=fodykaxrk izek.k i=fodykaxrk izek.k i=fodykaxrk izek.k i=)

    eSa] MkW...jft0 ua0..tkap dh] fd Jh/ Jherh/ dqekjh

    vk;qfyaxigpu

    fpUg~.........

    gS] fuEu oxZdh LFkk;h fodykaxrk lsihfMr gS%&

    vaxfguvaxfguvaxfguvaxfgu/ vfLFk laca/khvfLFk laca/khvfLFk laca/khvfLFk laca/kh/ efLrd i{kk?kkrefLrd i{kk?kkrefLrd i{kk?kkrefLrd i{kk?kkr %%%%

    nksukSa iSjksa ls izHkkfor ijUrqckagksa ls ugha

    nksukssa ckgkssa ls izHkkfor 1 [kjkc igqWap2 idM dh detksjh

    nksukssa iSjkssa vkSj nksukssa ckagksa ls izHkkfor

    ,d iSj ls izHkkfo(nkfguk ;k ck;ka) 1 [kjkc igqWap2 idM dh detksjh3 xfrfoHkzeh

    ,d gkFk ls izHkkfor(nkfguk ;k ck;ka) 1 [kjkc igqWap2 idM dh detksjh3 xfrfoHkzeh

    ihB vkSj dwYgksssa dh gM~Mh(uhps cSB ldrs gSa ;k ugha)

    ekalisfk;kssa esas detksjh vkSj lhfer kkjhfjd lgukfDr

    n`f"Vghurk ;k den`f"Vghurk ;k den`f"Vghurk ;k den`f"Vghurk ;k detksj n`f"V %tksj n`f"V %tksj n`f"V %tksj n`f"V %1 va/kk2 vkafkd #i ls CykbaM

    lquus esa ijskkuh gksrh gks %lquus esa ijskkuh gksrh gks %lquus esa ijskkuh gksrh gks %lquus esa ijskkuh gksrh gks %1 cgjk2 vkafkd #i ls cgjs

    (ml Js.kh dks gVk,Wa tks Hkh ykxwugha gml Js.kh dks gVk,Wa tks Hkh ykxwugha gml Js.kh dks gVk,Wa tks Hkh ykxwugha gml Js.kh dks gVk,Wa tks Hkh ykxwugha gSAS ASASA)

    ;g voLFkk izxfrkhy/ xSj izxfrkhy/ esalq/kkj gksusdh laHkkouk/ lq/kkj gksusdh laHkkouk ughagSA fQj ls bl ekeystkap dh vko;drk

    ughagS] ;fn gSrks...eghus/ oZ dh vof/k dsckn A

    bldsekeysesafodykaxrk.. izfrkr(...%)gSA

    Jh/ Jherh/ dqekjh.. viuh fuEufyf[kr kkjhfjd lerkvksadks[kkspqdk gSA

    D;k maxfy;ksa ds lkFk NsM[kkuh ds dke dj ldrh/ldrk gSA gka ugha

    D;k [khap vkSj tksj ds dke dj ldrh/ldrk gSA gka ugh D;k mBkus ds dk;Z dj ldrh/ldrk gSaA gka ugh

    D;k ?kqVuk Vsddj vkSj rys fcrk;k ls dke dj ldrh/ldrk gSA gka ugh

    D;k >wdus ds dke dj ldrh/ldrk gSA gka ugh

    D;k cSB dj dke dj ldrh/ldrk gSA gka ugh

    D;k [kMs djus ls dke dj ldrh/ldrk gSA gka ugh

    D;k pyus ls dke dj ldrh/ldrk gSA gka ugh

    D;k ns[k dj dke dj ldrh/ldrk gSA gka ugh

    D;k lqu dj dke dj ldrh/ldrk gSA gka ugh

    D;k i