persons with disabilities form
TRANSCRIPT
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8/9/2019 Persons with disabilities form
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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
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8/9/2019 Persons with disabilities form
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