CERTIFICATE FOR THE PERSONS WITH DISABILITIES

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

Certificate No……………..………….. Date…………….………………
DISABILITY CERTIFICATE
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 (can’t 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) 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) Percentage of disability in his/ her case is ………………...............................................................................................
Percent (…………………………………………………….………….. %)
4) Sh./Smt./Kum. ………………………………………………………………..………… meets the following
physical requirements for discharge of his/her duties:-
Affix here recent

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

PP-can perform work by pulling & pushing. Yes No Affix here recent
showing
attested the
photograph

L-can perform work by lifting. Yes No
disability
showing duly
the disability

KC-can perform work by kneeling & crouching. Yes No attested bybythe
duly attested the

B-can perform work by bending. Yes No Medical Board
Medical Board

S-can perform work by sitting. Yes No Chairperson
Chairperson

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 isab i l i t y cer t i f ica te should be issued by a Govt . Hosp i ta l
 fu%’kDr (fodyka
fodykax) O;fDr;ksa ds fy, izek.k i=
tkjh djus okys vLirky/ laLFkk dk uki vkSj irk (eksgj ds lkFk) ……………………………………………………
izek.k i= la[;k……………………… frfFk ………………………
fodykaxrk izek.k i=)
(fodyka i=
eSa] MkW……………………………………………...jft0 ua0……………………..………………tkap dh] fd Jh/ Jherh/ dqekjh
…………………………………………………………………………………vk;q………………fyax………………igpu
fpUg~ ………………………………………………………………………......... gS] fuEu oxZ dh LFkk;h fodykaxrk ls ihfMr gS%&
 vaxfgu/
fgu vfLFk laca/kh/
kh efLr’d i{kk?kkr %
 nksukSa iSjksa ls izHkkfor ijUrq ckagksa ls ugha
 nksukssa ckgksas ls izHkkfor 1 [kjkc igqWap
2 idM dh detksjh
 nksukssa iSjkssa vkSj nksukssa ckagksa ls izHkkfor
 ,d iSj ls izHkkfo (nkfguk ;k ck;ka) 1 [kjkc igqWap
2 idM dh detksjh
3 xfrfoHkzeh
 ,d gkFk ls izHkkfor(nkfguk ;k ck;ka) 1 [kjkc igqWap
2 idM dh detksjh
3 xfrfoHkzeh
 ihB vkSj dwYgkssa dh gM~Mh (uhps cSB ldrs gSa ;k ugha)
 ekalisf’k;kssa esas detksjh vkSj lhfer ’kkjhfjd lgu’kfDr
 n`f"Vghurk ;k detks
detksj n`f"V %
1 va/kk
2 vkaf’kd #i ls CykbaM
 lquus esa ijs’kkuh gksrh gks %
1 cgjk
2 vkaf’kd #i ls cgjs

ml Js.kh dks gVk,Wa tks Hkh ykxw ugha gSgSA)

(ml
• ;g voLFkk izxfr’khy/ xSj izxfr’khy/ esa lq/kkj gksus dh laHkkouk/ lq/kkj gksus dh laHkkouk ugha gSA fQj ls bl ekeys tkap dh vko’;drk
ugha gS] ;fn gS rks ……………………….………………..…eghus/ oÔZ dh vof/k ds ckn A
• blds ekeys esa fodykaxrk ………………………………………………..…… izfr’kr (……………………...%)gSA
• Jh/ Jherh/ dqekjh ………………………………………..…………… viuh fuEufyf[kr ’kkjhfjd lerkvksa dks [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 ;gkWa gky gh essa

D;k ?kqVuk Vsddj vkSj rys fcrk;k ls dke dj ldrh/ ldrk gSA gka ugh lk{;kafdr fof/kor

D;k >wdus ds dke dj ldrh/ ldrk gSA gka ugh esfMdy cksMZ ds v/;{k

D;k cSB dj dke dj ldrh/ ldrk gSA gka ugh }kjk vuqizekf.kr

D;k [kMs djus ls dke dj ldrh/ ldrk gSA gka ugh fodykaxrk fn[kk rLohj

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<us vkSj fy[kus ds dke dj ldrh/ ldrk gSaA gka ugh

mEehnokj ds gLrk{kj

fpfdRld ds gLrk{kj fpfdRld ds gLrk{kj fpfdRld ds gLrk{kj

uke ………………………….. uke……………………........
uke uke……………………………
uke
jft0 Uka0………………………. jft0 ua0…………………...... jft0 ua0…………………….....
lnL;]
lnL;] fpfdRlk cksMZ lnL;] fpfdRlk cksMZ v/;{k] fpfdRlk cksMZ

izfrgLrk{kfjr fpfdRlk v/kh{kd/

v/kh{kd v/;{k fpfdRlk dk;kZy;/ ;
vLirky ds izeq[k/k v/;{k] fpfdRlk cksMZ(eksgj ds lkFk)
lkFk
uksV %& fu%’kDrrk izek.k i= dsoy dsUnzh; ;k jkT; ljdkj ds gLirky }kjk tkjh fd;k tkuk pkfg, A