APPLICATION FORM FOR DISABILITY CERTIFICATE ANNEXURE-A NAME & ADDRESS OF THE Certificate No. Date Recent Photograph of the candidate showing the disability duly attested by the Chairperson of the Medical Board. This is certified that Son/ Wife/ Daughter of Shri age Sex FemaleMale Identification mark(s) is suffering from permanent disability of following category: (i) A. Locomotor/ Cerebral palsy (ii) (iii) (iv) (v) (vi) (vii) BL- Both legs affected but not arms. BA- Both arms affected (a) (b) Impaired reach Weakness of grip BLA- Both legs and both arms affected OL- One leg affected ( right left )or (a) (b) (c) Impaired reach Weakness of grip Ataxic OA- One leg affected (a) (b) (c) Impaired reach Weakness of grip Ataxic BH- Stiff back and hips (Cannot sit or stoop) MW- Muscular weakness and limited physical endurance Low VisionBlindness orB. (ii) (i) PB- Partially Blind B- Blind C. Hearing Impairment (ii) (i) PD- Partially Deaf D- Deaf (Delete the category whichever is not applicable) Delete Delete Delete Published on National Portal of India (india.gov.in) INSTITUTE/ HOSPITAL Shri/ Smti/ Kum 2. This condition is Re-assessment of this case years months. progressive/ non-progressive/ likely to improve/ not likely to improve. is not recommended/ is recommended after a period of 3. Percentage of disability in his/her case is percent. 4. Kum following physical requirements for discharge of his/her duties :- (i) (ii) (iii) (iv) (v) (vi) (vii) (viii) (ix) (xi) (x) F- can perform work by manipulating with fingers. PP- can perform work by pulling and pushing. L- can perform work by lifting. CK- can perform work by kneeling and crouching. B- can perform work by bending. S- can perform work by sitting. ST- can perform work by standing. W- can perform work by walking. SE- can perform work by seeing. H- can perform work by hearing/speaking. RW- can perform work by reading and writing. Yes No Yes No Yes No Yes No No Yes Yes No Yes No No Yes Yes No Yes No Yes No (Dr ) Member Medical Board (Dr ) Member Medical Board (Dr ) Member Medical Board Signature Signature Signature Published on National Portal of India (india.gov.in) Shri/ Smti/ Meets the STANDARD FORMAT OF THE CERTIFICATE ANNEXURE-B NAME & ADDRESS OF THE DateCertificate No. CERTIFICATE FOR THE PERSONS WITH DISABILITIES This is to certify that Son/ Wife/ Daughter of Shri Female,Male/Age years old Registration No. is a case of He /She is physically disabled visual disabled speech & hearing disabled and has % ( percent) permanent ( physical impairment visual impairment speech & hearing impairment) in relation to his/her Note:- 1. This condition is progressive/non-progressive/likely to improve/ not likely to improve 2. Re-assessment is not recommended/is recommended after a period of months/years. *Strike out which is not applicable Sd/-(DOCTOR) Seal Sd/-(DOCTOR) Seal Sd/-(DOCTOR) Seal Signature/Thumb impression Of the patient Countersigned by the Head of Hospital (with seal) Medial Superintendent/ CMO/ Recent Attested Photograph showing the disability affixed here. Published on National Portal of India (india.gov.in) INSTITUTE/ HOSPITAL issuing the certificate Shri/ Smt/ Kum
