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Disability Certificate - 3

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nagendra m
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30 views2 pages

Disability Certificate - 3

Uploaded by

nagendra m
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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FORM-PwD(IV)

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.

1. His/her extent of percentage of 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 Diagnosis Permanent physical


Part of Body 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.)
@ - e.g. Left/Right/both arms/legs
# - e.g. Single eye/both eyes
£ - e.g. Left/Right/both ears
2. The above condition is progressive/ non-progressive/ likely to improve/ not
likely to improve.

3. Reassessment of disability is:


a. not
necessary
Or
b. is recommended/after years months, and therefore this
certificate shall be valid till (DD/MM/YY)

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.

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