FORM FOR PHYSICALLY DISABLED CATEGORY
I, Dr. _________________________ Regn. No. _______________ examined Shri/Smt./Kum. ____________________ whose particulars are given below and hereby certify that he/she is a permanent physically disabled person of the following category:-
| (i) | BL-Both Legs affected but not arms. | |
| (ii) | BA-Both arms affected | (a) Impaired reach (b) Weakness of grip |
| (iii) | 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 | |
| (viii) | B-Blind | |
| (ix) | PD-Partially Deaf | |
| (x) | D-Deaf | |
| (Delete the category whichever is not applicable) | ||
2. The percentage of disability in hi/her case is ___________________.
3. Shri/Smt/Kum _______________ meets the following physical requirement for discharge of his/her duties:-
| (i) | F-Work performed by manipulating with fingers. |
| (ii) | PP-Work performed by pulling and pushing |
| (iii) | L-Work performed by lifting |
| (iv) | KC-Work performed by kneeling and chrouching. |
| (v) | B-Work performed by bending |
| (vi) | S-Work performed by sitting |
| (vii) | ST-Work performed by standing |
| (viii) | W-Work performed by walking |
| (ix) | SE-Work performed by seeing |
| (x) | H-Work performed by hearing/speaking |
| (xi) | RW-Work performed by reading and writing |
| (Delete whichever is not applicable) | |
4. Shri/Smt/Kum ___________ does not suffer from disease (communicable or otherwise), constitutional weakness or bodily infirmity that may interfere with the efficient discharge of his/her duties as an Officer under the Govt. of India.
(i)
Name of the Candidate ______________________________
(ii) Father's
Name
_______________________________
(iii) Indentification Marks
_______________________________
(iv)
Sex
______________________________
(v)
Age
______________________________
Signature of Surgeon/Medical
Officer
Designation________________
Signature of Candidate
Office Stamp
________________
Address ____________________
Note: The disability certificate should be issued by a Govt. Hospital