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CERTIFICATE FOR PHYSICALLY HANDICAP OF U.P.
NAME & ADDRESS OF T}IE INSTITUTE/HOSPITAL
CERTIFICATE No.
DISABILITY CERTIFICATE
This is certified that Shri/Smt./Kum.
Son/Wife/Daughter of
Sex...
Shri
.
.. age
..... identification mark
(S)
is
suffering
from permanent disability of following category.
Locomotor of cerebral palsy
BL-Both legs affected but not arTns.
BA-Both arms affected
impaired reach
Weakness of grip
A.
(i)
(ii)
(iiD
(iv)
BLA-Both legs and both arms affected
OL-One leg affected (right or left)
(a)
(b)
(c)
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)
(vii) MW-Muscular weakness and limited physical endurance.
Blindness or Low vision.
(v)
(vi)
B.
(a)
(b)
(i)
(iD
(a)
(b)
(c)
B-Blind
PB-Partially Blind
Hearing Impairment:
D-Deaf
PD-Parlially Deaf
(Delete the category whichever is not applicable)
The condition is progressive/non-progressive/likely to improve/not likely to
improve. Re-assess of the case is not recommended/is recommended after a period of
... .....months.
Percentage of disability in his/her case
. . . .. percent.
C.
(D
(ii)
2.
3.
4.
.....year.
is
Shri/Smt.a(um.
Meets the following physical
requirements discharge of his/her duties:
F-can perform work by manipulating (with
(i)
(ii)
(iii)
(iv)
PP-can perform work by pulling and
L-can perform work by
(vi)
(vii)
sitting.
ST- can perform work by standing.
lifting.
pushing.
KC-can perform work by kneeling and
S-can perform work by
fingers.)
YesA.{o
YesA.{o
YesA.{o
couching.
YesA{o
YesA.lo
YesA.[o
(viii)
(ix)
(x)
(xi)
W- can perform work by walking.
SE-can perform work by seeing.
H- can perform work by hearing/speaking.
RW-can perform work by reading and writing.
(Dr...
(Dr.
Member
Medical Board
......)
Member
Medical Board
YesA.{o
YesA.{o
YesA.{o
YesA.{o
(Dr...
.........)
Chairperson
Medical Board
Countersigned by the
Medical Superintendent/
cM9/HQ
Hospital (with seal)
Strike out which is not applicable.
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