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NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

Certificate No. ………………………….. Date ……………………….

DISABILITY CERTIFICATE

This is certified that Shri/Smt/Kum …………………………………………… Son/wife/

daughter of Shri …………………………………… age …………………….

Sex……………………… identification mark(s) .................... is suffering from permanent

disability of following category:-

A. Locomotor or cerebral palsy:

(i) BL – Both legs affected but not arms.

(ii) BA-Both arms affected

(a) Impaired reach

(b) Weakness of grip

(iii) BLA-Both legs and both arms affected

(iv) OL-one leg affected (right or left)

(a) Impaired reach

(b) Weakness of grip

(c) Ataxic

(v) OA-One arm affected

(a) Impaired reach

(b) Weakness of grip

(c) Ataxic

(vi) BH- Stiff back and hips (cannot sit or stoop)

(vii) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low Vision: (i) B-Blind

(ii) PB-Partially Blind

C. Hearing Impairment : (i) D-Deaf

(ii) PD-Partially Deaf

(DELETE THE CATEGORY WHICHEVER IS NOT APPLICABLE)

2. This condition is progressive/non-progressive/likely to improve/not likely to

improve. Reassessment of this case is not recommended/is recommended after a period of

…………….. years ………….months. *

3. Percentage of diability in his/her case is …………………………………. Percent.

4. Shri/Smt/Kum …………………….. meets the following physical requirements

for discharge of his/her duties:-

(i) F-can perform work by manipulating with fingures Yes/No

(ii) PP-can perform work by pulling and pushing Yes/No

(iii) L-can perform work by lifting Yes/No

(iv) KC-can perform work by kneeling and crouching Yes/No

(v) B-can perform work by bending Yes/No

(vi) S-can perform work by sitting Yes/No

(vii) ST-can perform work by standing Yes/No

(viii) W-can perform work by walking Yes/No

(ix) SE-can perform work by seeing Yes/No

(x) H-can perform work by hearing/speaking Yes/No

(xi) RW-can perform work by reading and writing Yes/No

Affix here recent attested

photograph showing the

disability duly attested by

the chairperson of the

Medical Board

(Dr…………………) (Dr………………………) (Dr. …………………….)

Member, Medical Member, Medical Board Chairperson, Medical Board

Board

Countersigned by the Medial Superintendent/

CMO/Head of Hospital (with seal)

* Strike out which is not applicable.

Note: IMPORTANT REQUIREMENT OF PH CERTIFICATE

(i) A disability certificate shall be issued by a Medical Board duly constituted by

the Central and the State Government. The state government may constitute a

Medical Board consisting of at least 3 Members out of which, at least, one

Member shall be a Specialist from the relevant field.

(ii) The Certificate would be valid for a period of 5 years for those whose disability

is temporary. For those who acquired permanent disability, the validity can be

shown as 'permanent'.

(iii) According to the Persons with Disabilities (Equal Opportunities Protection of

Right and full Participation) Rules, 1996 notified on 31.12.1996 by the Central

Government in exercise of the powers conferred by sub-section (1) and (2)

section 73 of the Persons with Disabilities (Equal Opportunities, Protection of

Right and full Participation) Act, 1995 (1 of 1996), authorities to give disability

Certificate will be a Medical Board duly constituted by the Central and the

State Government. The State Government may constitute a Medical Board

consisting of at least three members out of which, at least one shall be a

specialist in the particular field for assessing locomotor/visual including low

vision/hearing and speech disability, Mental retardation and leprosy cured, as

the case may be.

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