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NAME & ADDRESS OF THE INSTITIUTE/HOSPITAL Certificate No. DISABILITY CERTIFICATE This is certified that Shri/smt/kum. ‘Son/Wife/ Daughter of Shri - age... oe SOX co Hentification mark ©). suse. 8 Suffering from permanent disabilty of following category. A. Loco motor of cerebral palsy: ()BL-Both legs affected but not arms. (i) BABoth arms affected © (a) Impaired reach ©) Weakness of rp (i BLA‘ath egs and both arms affected (iv) ‘OL-One leg affected (right or left) (a) Impaired reach ©) Weakness of orp () Ataxic ™ OA-One arm affected (a) Impaired reach ©) Weakness of rp co} Ataxic (v) —_BHASUf back and hips (cannot sito stoop) (wi) MW-Muscular weakness and ited physical endurance B. Blindness or Low Vision : @ B-Blind i PB-Partialy Blind ©. Hearing Impsiment @ D-Deaf wi) PD-Partialy Deaf (Delete the category whichever is not applicable) 2. This condition is progressive/non-progressiveflkely to improve/not likely to improve. Re-assessn of this case is not recommendediis recommended after a period of oo YR months. 3. Percentage of disabilty in his her case is, percant 4. Sh/Smt/Kum. meets the following physical requirements discharge of hisiner duties: ()—F-can perform work by manipulating with figers. YesiNo (i) PP-can perform work by pulling and pushing, YesiNo (ii) Lean perform work by iting. YesiNo (vy) __KC-can perform work by kneeling and couching, YesiNo (¥)_ B-can perform work by bending YesiNo (wi) S-can perform work by sitting YesiNo (vil) ST-can perform work by standing YesiNo (wii) Wecan perform work by walking YesiNo (>) SE-can perform work by seeing YesiNo (%)_-Hecan perform work by hearing/speaking YesiNo (x) RWecan perform work by reading and writing YesiNo (Or. ) (or. ) (Or. ) Member Member ‘Chairpersion Medical Board Medical Board Countersingned by the Medical ‘Superintendent cmon Hospital (wth seal)Strike out which is not applicable, aftftre-2 ser ste & ara fog af 8 fg wana wats fie ort fat aia. . waar — ceed RTE TA, meet, am. a A BAR FET THB frog any & mafia me ae Go we aw Ba a a, er rat eT at frre at Fd ern) Pam, 1994 Geman) arg we Barer aT aT 8 ae oa frat ara A A/a / AA... apts ace, soos (aereieta) 3 argapll—eh (Che fi sew weer ates Bex) Caaf Re, age SHAR gy a fower wit & fed orem) (eters) a, 2001 are wfteenftt rar rar & ye GH we wee a ar (ote outa, gates arronat tke are Rewer eat & Fa ser) (eter) em, zo02 ere rr Bh ahh &, 8 once aah By ga Tefen Pree A al A aA fA Aer a re are wd a get tw aE 8 aT gm OTH ora APE, 1087 Fae AAR UE eta & rater of 38 1 A/a apa. cn aera we GPa SOR HET .. aed a. far 3 arr wT tl - er. 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