Disability Certificates Format

FORM-II

DISABILITY CERTIFICATE

NAME AND ADDRESS OF THE INSTITUTE/HOSPITAL

Certificate No.:____________________
Date:_______________

This is certified that Shri/Smt/Kum_______________son/wife/daughter of Shri_______age _________sex_______with identification marks ________________is suffering from permanent disability(40% or more) of following category:-

A. Locomotors of 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) BH-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 of Low Vision:-

D- Deaf

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 disability in his/her case is__________ Percentage.

Sh/Smt/Kum_______________meets the following physical requirement for discharge of his/her duties:-

(i) F – can perform work by manipulating with fingers – 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 seeing – Yes/No

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

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

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