Performa-V

The form of certificate to be produced by Physically Handicapped candidates applying

for appointment to posts under the Government of India.

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL

CertiIicate No. ................................... Date: ..........................

DISABILITY CERTIFICATE


Recent Photograph oI
the candidate showing
the disability duly
attested by the
Chairperson oI the
Medical Board

This is certiIied that Shri/Smt./Kum. ...............................son/wiIe/daughter oI Shri
......................................... age ..........sex ............ identiIication mark(s) ........................ is
suIIering Irom permanent disability oI Iollowing category :

A. Locomotor or Cerebral Palsy:

(i) BLBoth legs aIIected but not arms

(ii) BABoth arms aIIected (a) Impaired reach
(b) Weakness oI grip

(iii) BLABoth legs and both arms aIIected

(iv) OLOne leg aIIected (right or leIt) (a) Impaired reach
(b) Weakness oI grip
(c) Ataxic

(v) OAOne arm aIIected (a) Impaired reach
(b) Weakness oI grip
(c) Ataxic

(vi) BHStiII back and hips (cannot sit or stoop)

(vii) MWMuscular weakness and limited physical endurance.

B. Blindness or Low Vision:

(i) BBlind

(ii) PBPartially blind
C. Hearing impairment:

(i) DDeaI

(ii) PDPartially deaI

(Delete the category whichever is not applicable)

2. This condition is progressive/non-progressive/likely to improve/not likely to improve.
Re-assessment oI this case is not recommended/is recommended aIter a period oI
................years ............................... months.*

3. Percentage oI disability in his/her case is....................... Per cent.

4. Shri/Smt./Kum. ...................................... meets the Iollowing physical requirements
Ior discharge oI his/her duties:

(i) FCan perIorm work by manipulating with Iingers. Yes/No
(ii) PPCan perIorm work by pulling and pushing. Yes/No
(iii) LCan perIorm work by liIting. Yes/No
(iv) KCCan perIorm work by kneeling and crouching. Yes/No
(v) BCan perIorm work by bending. Yes/No
(vi) SCan perIorm work by sitting. Yes/No
(vii) STCan perIorm work by standing. Yes/No
(viii) WCan perIorm work by walking. Yes/No
(ix) SECan perIorm work by seeing. Yes/No
(x) HCan perIorm work by hearing/speaking. Yes/No
(xi) RWCan perIorm work by reading and writing. Yes/No




(Dr.......................) (Dr......................) (Dr. ..................)
Member Member Chairman
Medical Board Medical Board Medical Board




Countersigned by the Medical
Superintendent/CMO/Head oI Hospital
(With seal)

* Strike out whichever is not applicable.