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Amended Rules for PWD - Form-IV 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-IV

Disability Certificate
(In cases other than those mentioned in Forms II and III)

(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 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) and is 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



(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
CMO/Medical Superintendent/Head of
Government Hospital, in case the
certificate is issued by a medical
authority who is not a government
servant (with seal)}

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

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."

Note: The principal rules were published in the Gazette of India vide notification number S.O. 908(E), dated the 31st December, 1996.

Form-V

Intimation of Rejection of Application for Disability Certificate (See rule 4)

No.____________________ Dated:

To,

(Name and address of applicant for Disability Certificate)

Sub.: Rejection of Application for Disability Certificate

Sir / Madam,

Please refer to your application dated ____ for issue of a Disability Certificate for the following disability: _____________________________________________

2. Pursuant to the above application, you have been examined by the undersigned/ Medical Board on _______, and I regret to inform that, for the reasons mentioned below, it is not possible to issue a disability certificate in your favour:

(i)

(ii)

(iii)

3. In case you are aggrieved by the rejection of your application, you may represent to ________________________________, requesting for review of this decision.

Yours faithfully,

(Authorised Signatory of the notified Medical Authority)
(Name and Seal)

(Dr. Arbind Prasad)
Joint Secretary to the Govt. of India
Ministry of Social Justice and Empowerment



Last Updated on Monday, 09 January 2012 14:45
 

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