CERTIFICATE FOR THE PERSONS WITH DISABILITIES
This is to certify that Shri/Smt/Kum_____________________________________________________________Son/wife/ daughter of Shri____________________________________________________ Age _______ old male/female, Registration No.___________________ is a case of __________________________ He/She is physically disabled/visual disabled/ speech & hearing disabled and has______% (_______per cent) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ___________________________.
1. This condition is progressive/non-progressive/likely to impreove/not likely to improve.* 2. Re-assessment is not recommended/is recommended after a period of ____________ __________________months/years.*
*Strike out which is not applicable.
Sd/- Sd/- Sd/- (DOCTOR) (DOCTOR) (DOCTOR) Seal Seal Seal
Signature/Thumb impression of the patient.
Countersigned by the Medial Superintendent/
CMO/Head of Hospital (with seal)
Recent Attested Photograph Showing the disability affixed Here.
STARDARD FORMAT OF THE DISABILITY CERTIFICATE