FORM OF CERTIFICATE TO BE PRODUCED BY PERSONS WITH DISABILITY APPLYING FOR APPOINTMENT TO POSTS UNDER THE GOVERNMENT OF INDIA Name

and address of the Institute or Hospital Certificate No Date Recent photograph of the candidate showing the disability duly attested by the Chairperson of the medical board This is certified that Shri / Smt / Kum son / wife / daughter of Shri age Identification marks (s) suffering from permanent disability of following category: A. Locomotor or cerebral palsy: (i) (ii) (a) (b) (iii) (iv) (a) (b) (c) (v) (a) (b) (c) (vi) (vii) BL Both legs affected but not arms BA Both arms affected Impaired reach Weakness of grip BLA Both legs and arms affected OL One leg affected (right or left) Impaired reach Weakness of grip Ataxic OA One arm affected Impaired reach Weakness of grip Ataxic BH Stiff back and hips (cannot sit or stoop) MW Muscular weakness and limited physical endurance.

is

B. Blindness or Low vision: (i) (ii) B Blind PB Partially Blind

C. Hearing Impairment (i) (ii) D Deaf 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 recommended / not recommended after period of years . Months. 3. Percentage of disability in his / her case is . Percent. 4. Shri. / Smt. / Kum meets the following physical requirements discharge of his / her duties :i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. F can perform work by manipulating with fingers PP can perform work by pulling and pushing No L can perform work by lifting No KC can perform work by kneeling and crouching No B can perform work by bending No S can perform work by sitting No ST can perform work by standing No W can perform work by walking No SE can perform work by seeing No H can perform work by hearing / speaking No RW can perform work by reading and writing No Yes / No Yes / Yes / Yes / Yes / Yes / Yes / Yes / Yes / Yes / Yes /

Dr... Member Chairperson Medical Board Medical Board

Dr. Member Medical Board

Dr

Counter signed by Medical Superintendent / CMO / HoD of Hospital (with seal)