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FORMV CERTIFICATE OF DISABILITY

(In cases of amputation or complete permanent paralysis of limbs or dwarfism and in case of blindness)

[ See rule 18(1)] (Name and Address of the Medical Authority issuing the Certificate)

Recent passport size attested photograph (Showing face only) of the person with disability. Date . Certificate No .

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:

(A) he/ she is a case of: • locomotor disability • dwarfism • blindness

(Please tick as applicable) (B) the diagnosis in his/her case is .

(A) he/she has % (in figure) percent (in words) permanent locomotor disability/ dwarfism/blindness in relation to his/her (part of body) as per guidelines ( number and date of issue of the guidelines to be specified). .

2. The applicant has submitted the following document as proof of residence:-

Nature of Document Date of Issue Details of authority issuing certificate

(Signature and Seal of Authorised Signatory of notified Medical Authority)

Signature/thumb impression of the person in whose favour certificate of disability is issued

FORM VI CERTIFICATE OF DISABILITY (In cases of multiple disabilities)

[See rule 18(1)] (Name and Address of the Medical Authority issuing the Certi~cate)

Recent passport size attested photograph (Showing face only) of the person with disability.

Certificate No. Date . This is to certify that we have carefully examined Shri/Smt./Kum .

son/wife/ daughter of Shri Date of Birth (DD /MM/YY) Age year,

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:

(A) he/ she is a case of Multiple Disability. His/her extent of permanent physical impairment/ disability has been evaluated as per guidelines ( number and date of issue of the guidelines to be specified) for the disabilities ticked below, and is shown ' against the relevant disability in the table below:

SL Disability Affected Diagnosis Permanent physical

No. part of impairment/mental

body disability (in % )

1. Locmnotor disability @

2. Muscular Dystrophy

3. Leprosy cured

4. Dwarfism

5. Cerebral Palsy '

6. Acid attack Victim

7. Low vision #

8. Blindness #

9. Deaf £

10. Hard of Hearing £

11. Speech and Language disability

12. Intellectual Disability

13. Specific Learning Disability

14. Autism Spectrum Disorder

15. Mental illness

16. Chronic Neurological Conditions

17. Multiple sclerosis

18. Parkinson' s disease

19. Haemophilia

20. Thalassemia

21. Sickle Cell disease · (B) In the light of the above, his/her over all permanent physical impairment as

per guidelines ( number and date of issue of the guidelines to be specified), is as follows:-·

In figures : percent In words: percent 2~ This condition ls progressive/non-progressive/likely to improve/not likely to

improve.

Form VII] The Rights of Persons with Disabilities Rules, 2017 71

3. 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)

@ e.g. Left/right/both arms/legs # e.g. Single eye £ e.g. Left/Right/both ears

4. The applicant has submitted the following document as proof of residence:-

Nature of document Date of issue Details of authority issuing certificate

5. Signature and seal of the Medical Authority.

Name and Seal of Member

Name and Seal. of Member

Name and Seal of the Chairperson

························································· Signature/thumb impression

of the person in whose favour certificate of disability is issued.

FORI\.1 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)]

Recent passport size attested photograph (Showing face only) of the person with disability

Certificate No ,. Date .

This is to certify that 1 have carefully examined Shri/Smt/Kuri.1 son/wife/ daughter of Shri Date of Birth

(DD /MM/YY) \7/Age years, male/ female .. A .••...•..• 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 physital impairment/ disability has been evaluated as per guidelines ( . number and date of issue of the guidelines to be specified) and is shown against the relevant disability in the table below:-

\ SL Disability Affected Diagnosis Permanent physical

No. part of impairment/ mental body > disability (in %)

1. Locomotor disability @

2. Muscular Dystrophy

3. Leprosy cured 4. Cerebral Palsy

5. Acid attack Victim

6. Low vision #

7. Deaf €

8. Hard of Hearing €

9. Speech and Language disability

10. Intellechrnl Disability '.

..

11. Specific Leaming Disability

12. Autism Spectrum Disorder

13. Mental illness

14. Chronic Neurological Conditions

15. · Multiple sclerosis

16. Parkinson's disease ,~

17. Haemophilia •'

18. Thalassemia 19: Sickle Cell disease

'

(Please strike out the disabilities which are not applicable) 2. The above condition is progressive/non-progressive/likely to improve/not likely

to improve. 3. 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) . @ - e.g. Left/Right/both arms/legs # - e.g. Single eye/both eyes € - e.g. Left/Right/both ears

4. The applicant has submitted the following document as proof of residence:-

Nature of document Date of issue 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) l

Signatili~/tntimb ~pression .. of the person in whose favour certificate of disability is issued Note.-Iri 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. ,;Cl

i j

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