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Amended Rules for PWD - Form-II PDF Print E-mail
Tuesday, 23 August 2011 15:56
Article Index
Amended Rules for PWD
Issue of disability certificate
Educational qualifications
Other terms and conditions of service of the Chief Commissioner
APPLICATION FOR OBTAINING DISABILITY CERTIFICATE BY PERSONS WITH DISABILITIES
Form-II
Form-IV
All Pages

Form-II

Disability Certificate
(In cases of amputation or complete permanent paralysis of limbs
and in cases of blindness)
(See rule 4)

(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE
CERTIFICATE)

Recent PP size Attested Photograph (Showing face only) of the person with disability

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 :

(A) he/she is a case of:

· locomotor disability

· blindness

(Please tick as applicable)

(B) the diagnosis in his/her case is ___________

(A) He/ She has ____________%(in figure)___________________________ percent (in words) permanent physical impairment/blindness in relation to his/her_________(part of body) as per 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 disability certificate is issued

Form-III

Disability Certificate
(In case of multiple disabilities)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE
CERTIFICATE)
(See rule 4)

Recent PP 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_______years, male/female____________________ Registration No.___________________________permanent resident of House No.___________________Ward/Village/Street_________________________________Post Office____________________________District_________State______________, whose photograph is affixed above, and are 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 (to be specified) for the disabilities ticked below, and shown against the relevant disability in the table below:

S. No.

Disability

Affected Part of Body

Diagnosis

Permanent physical impairment/mental disability (in %)

1

Locomotor disability

@



2

Low vision

#



3

Blindness

Both Eyes



4

Hearing impairment

£



5

Mental retardation

X



6

Mental-illness

X



(B) In the light of the above, his /her over all permanent physical impairment as per guidelines(to be specified), is as follows:-

In figures:- __________________percent

In words:-_______________________________________________________percent

2. This 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




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 disability certificate is issued



Last Updated on Monday, 09 January 2012 14:45
 

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