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    Format of Medical Certificate For Persons With Disabilities (PWD) Name and Address of The Institute/ Hospital

    Uploaded by

    Yash Mane
    This medical certificate provides details on certifying a person's disability. It includes: 1. Personal information of the individual such as name, age, sex, identification marks and category of permanent disability which can be locomotor, cerebral palsy, blindness, low vision, or hearing impairment. 2. Classification of the disability as progressive, non-progressive or likely/not likely to improve along with recommendation for re-assessment. 3. Percentage of assessed disability. 4. Assessment of individual's ability to perform various physical tasks and their capacity for work.

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    Format of Medical Certificate For Persons With Disabilities (PWD) Name and Address of The Institute/ Hospital

    Uploaded by

    Yash Mane
    1K views1 page
    This medical certificate provides details on certifying a person's disability. It includes: 1. Personal information of the individual such as name, age, sex, identification marks and category of permanent disability which can be locomotor, cerebral palsy, blindness, low vision, or hearing impairment. 2. Classification of the disability as progressive, non-progressive or likely/not likely to improve along with recommendation for re-assessment. 3. Percentage of assessed disability. 4. Assessment of individual's ability to perform various physical tasks and their capacity for work.

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    PWD.pdf

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    This medical certificate provides details on certifying a person's disability. It includes: 1. Personal information of the individual such as name, age, sex, identification marks and category of permanent disability which can be locomotor, cerebral palsy, blindness, low vision, or hearing impairment. 2. Classification of the disability as progressive, non-progressive or likely/not likely to improve along with recommendation for re-assessment. 3. Percentage of assessed disability. 4. Assessment of individual's ability to perform various physical tasks and their capacity for work.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    1K views1 page

    Format of Medical Certificate For Persons With Disabilities (PWD) Name and Address of The Institute/ Hospital

    Uploaded by

    Yash Mane
    This medical certificate provides details on certifying a person's disability. It includes: 1. Personal information of the individual such as name, age, sex, identification marks and category of permanent disability which can be locomotor, cerebral palsy, blindness, low vision, or hearing impairment. 2. Classification of the disability as progressive, non-progressive or likely/not likely to improve along with recommendation for re-assessment. 3. Percentage of assessed disability. 4. Assessment of individual's ability to perform various physical tasks and their capacity for work.

    Copyright:

    © All Rights Reserved
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    of 1

    FORMAT OF MEDICAL CERTIFICATE FOR PERSONS WITH DISABILITIES (PWD)

    NAME AND ADDRESS OF THE INSTITUTE/ HOSPITAL

    Certificate No. …………………..


    Date : ………………...
    DISABILITY CERTIFICATE
    Paste here your recent colour
    photograph showing the
    1. This is to certify that Shri/Smt./Kum ………………………………………………
    disability (The photograph
    son/daughter of Shri ……………………………..…………………………………
    age……………………, sex Male/Female having identification marks as below : should be attested by the
    ……………………………………………………….……..………………………... chairperson of the Medical
    is suffering from permanent disability of the following category : Board)
    A. Locomotor or cerebral palsy :
    (i) BL – Both legs affected but not arms.
    (ii) BA – Both arms affected
    (a) Impaired reach
    (b) Weakness of grip.
    (iii) OL – One leg affected (right or left) Signature of the candidate
    (a) Impaired reach
    (b) Weakness of grip.
    (c) Ataxic
    (iv) OA – One arm affected (right or left)
    (a) Impaired reach
    (b) Weakness of grip.
    (c) Ataxic
    (v) BH – Stiff Back and hips (cannot sit or stoop)
    (vi) MW – Muscular Weakness and limited physical endurance.
    B. Blindness or Low Vision : C. Hearing Impairment:
    (i) B-Blind (ii) PB- Partially Blind (i) D-Deaf (ii) PD- Partially Deaf.
    (Delete the category whichever is not applicable)
    2. This condition is progressive/non-progressive/likely to improve/ not likely to improve.
    Re-assessment of this case is not recommended/ recommended after a period of ________ Years____________Months.
    3. Percentage of disability in his/ her case is _______________________ Percent.
    4. Smt./Shri/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 by seeing. Yes No
    (x) H – can perform work by hearing/speaking. Yes No
    (xi) RW- can perform work by reading and writing. Yes No

    (Signature of Doctor) (Signature of Doctor) (Signature of Doctor)


    Name : Name: Name :
    Registration No. Registration No. Registration No.
    Member, Medical Board Member, Medical Board Member/Chairperson,
    Medical Board

    *Please delete the words which are not applicable.


    Place :
    Date:
    Counter Signature of the Medical Superintendent/CMO/
    Head of Hospital (with seal)

    Note :- (i) According to the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full participation) Rules, 1996 notified on
    31.12.1996 by the Central Government in exercise of the powers conferred by sub-section
    (1) and (2) of Section 73 of the Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act, 1995 (1 of 1996),
    authorities to give disability Certificate will be a Medical Board duly constituted by the Central or the State Government may constitute a Medical
    Board consisting of t least three members out of whom at least one shall be a specialist in the particular field for assessing locomotor / hearing
    and speech disability, mental retardation and leprosy cured, as the case may be.
    (ii) The certificate would be valid for a period of 5 years for those whose disability is temporary. For those who acquired permanent disability, the
    validity can be shown as permanent.

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