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soso d ff{mtrit d lili n-flur-wrCERTIFICATE FOR PHYSICALLY HANDICAP OF U.P.

NAME & ADDRESS OF T}IE INSTITUTE/HOSPITALCERTIFICATE No.DISABILITY CERTIFICATE

This is certified that Shri/Smt./Kum.

Son/Wife/Daughter of Shri .. age

Sex... . ..... identification mark (S) is suffering

from permanent disability of following category.

A. Locomotor of cerebral palsy

(i) BL-Both legs affected but not arTns.

(ii) BA-Both arms affected

(a) impaired reach

(b) Weakness of grip(iiD BLA-Both legs and both arms affected(iv) OL-One leg affected (right or left)

(a) Impaired reach

(b) Weakness of grip(c) Ataxic

(v) OA-One arm affected

(a) Impaired reach

(b) Weakness of grip(c) Ataxic

(vi) BH-Stiff back and hips (Cannot sit or stoop)

(vii) MW-Muscular weakness and limited physical endurance.

B. Blindness or Low vision.(i) B-Blind(iD PB-Partially Blind

C. Hearing Impairment:(D D-Deaf(ii) PD-Parlially Deaf(Delete the category whichever is not applicable)

2. The condition is progressive/non-progressive/likely to improve/not likely toimprove. Re-assess of the case is not recommended/is recommended after a period of

.....year. ... .....months.3. Percentage of disability in his/her case is . . . .. percent.

4. Shri/Smt.a(um. Meets the following physicalrequirements discharge of his/her duties:(i) F-can perform work by manipulating (with fingers.) YesA.{o

(ii) PP-can perform work by pulling and pushing. YesA.{o(iii) L-can perform work by lifting. YesA.{o(iv) KC-can perform work by kneeling and couching. YesA{o

(vi) S-can perform work by sitting. YesA.lo(vii) ST- can perform work by standing. YesA.[o

(viii) W- can perform work by walking.(ix) SE-can perform work by seeing.

(x) H- can perform work by hearing/speaking.

(xi) RW-can perform work by reading and writing.

(Dr.

YesA.{o

YesA.{o

YesA.{o

YesA.{o

Member

Medical Board

(Dr... ......)Member

Medical Board

(Dr... .........)Chairperson

Medical Board

Countersigned by the

Medical Superintendent/

cM9/HQHospital (with seal)

Strike out which is not applicable.

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