Proforma of Disability Certificate PDF

Download Proforma of Disability Certificate PDF

You can download the Proforma of Disability Certificate PDF for free using the direct download link given at the bottom of this article.

File nameProforma of Disability Certificate PDF
No. of Pages8  
File size158 KB  
Date AddedSep 7, 2022  
CategoryGovernment  
LanguageEnglish  
Source/CreditsDrive Files        

Proforma of Disability Certificate Overview

A disability certificate (also known as PwD certificate or PH certificate or handicap certificate) is a document that certifies the type and extent of holder’s disability. In India, this certificate is usually issued by medical boards constituted in certain government hospitals.

Disability Certificate Issuing Authorities (CMO Office/Medical Authority) will use this application to record the details of Persons with Disabilities (PwDs) and issue Disability Certificate/UDID Card electronically. Application from the PwD will be received by the CMO Office/Medical Authority.

Form-VII
Certificate of Disability
(In cases other than those mentioned in Forms V and VI)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE
CERTIFICATE)
[See rule 18(1)]

Certificate No. ………………………

Date: ………………….


This is to certify that I have carefully examined Shri/Smt./Kum …………………… son/wife/daughter of Shri ………………………Date of Birth………………….. (DD)/(MM)/(YY) Age …………. years,male/female………………. Registration No. ……… permanent resident of House No…………….. Ward/Village/Street ………….Post Office ……… District…………… State ……………………………….whose photograph is affixed above, and am satisfied that he/she is a case of ……………………… disability. His/her extent of percentage physical impairment/disability has been evaluated as
per guidelines (to be specified) .

  • The above condition is progressive/ non-progressive/ likely to improve/not likely to improve.
  • Reassessment of disability is :
    (i) not necessary
    Or
    (ii) is recommended/ after ………………….. years ………………….months, and therefore this certificate shall be valid till ……………
    ………………… (DD)/(MM)/(YY)
    eg. Left/Right/both arms/legs
    • eg. Single eye/both eyes
    • eg. Left/Right/both ears

The applicant has submitted the following document as proof of residence:-
1. Nature of Document
2. Date of Issue –

3. Details of authority issuing certificate


(Authorised Signatory of notified Medical Authority)
(Name and Seal)
Countersigned
(Countersignature and seal of the
Chief Medical Officer/Medical Superintendent/
Head of Government Hospital, in case the
certificate is issued by a medical
authority who is not a government
servant (with seal))

Note: In case this certificate is issued by a medical authority who is not a government servant, it shall be valid only if countersigned by the Chief Medical Officer of the District.
The principal rules were published in the Gazette of India by Ministry of Social Justice and Empowerment vide notification number 489, dated 15.06.2017.

Proforma of Disability Certificate PDF

Proforma of Disability Certificate PDF Download Link

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