Scribd
Upload
256 views1 page

Annexure 6 (B) - Compressed

This document is a Certificate of Disability for individuals with multiple disabilities, issued by a medical authority. It includes details about the individual's identity, the nature and extent of their disabilities, and the validity of the certificate. The certificate also requires signatures from the medical authority members and the individual receiving it.

Uploaded by

mallikarjunayasam89
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
256 views1 page

Annexure 6 (B) - Compressed

This document is a Certificate of Disability for individuals with multiple disabilities, issued by a medical authority. It includes details about the individual's identity, the nature and extent of their disabilities, and the validity of the certificate. The certificate also requires signatures from the medical authority members and the individual receiving it.

Uploaded by

mallikarjunayasam89
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

ANNEXURE –VI (B)

FORM-VI
Certificate of Disability
(In case of multiple disabilities)
[See Rule 18(1)]
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE)

Certificate No.:………………………………… Date: ………………………. Recent Passport Size


Attested Photograph
1. This is to certify that we have carefully examined Shri/Smt./ Kum (Showing face only) of
……………………………………………….…….. son/wife/daughter Of Shri the person with
…………………………….……..… Date of Birth……………………(DD/MM/YYYY) disability
Age………….years, Male/Female ……………Registration No. ……………......... Permanent
Resident of House No. ….….. Ward/Village/Street ………….…………….. 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 Diagnosis Permanent Physical Impairment/ Mental
Body Disability (in%)

1 Locomotors 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 Hemophilia
20 Thalassemia
21 Sickle Cell disease
(B) In the light of the above, his/her overall 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 ……………….Year …………………….…months, and therefore this certificate shall be valid till
……………………………………………(DD/MM/YYYY)
@ 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

21

You might also like