DISABILITY CERTIFICATE for SSC CGL Exam

Annexure-VIII (FORM-II)

DISABILITY CERTIFICATE

(IN CASE OF AMPUTATION OR COMPLETE PERMANENT PARALYSIS

OF LIMBS AND IN CASES OF BLINDNESS)

(See rule 4)

Recent PP size

Attested Photograph (showing face only) of the person with disability

(NAME AND ADDRESS OF THE MEDICAL AUTHORTIY ISSUING THE CERTIFICATE)

Certificate No.                                                                                    Date:

This is to certify that I have carefully examined Shri/Smt/Kum _______________

Son/wife/daughter of Shri _________________________________ Date of Birth

____ ____ ________ Age _______________  years, male/Female___________

(DD/ MM/ YY)

Registration    No.___________________  permanent  resident  of  House  No

_____________________ Ward/Village/Street ________________ Post Office______________ District_____________ State________________________

Whose photograph is affixed above, and am satisfied that :

(A) he/she is a case of: · locomotor disability · blindness

(Please tick as applicable)

(B)  Tthe diagnosis in his/her case _____________________________

(A) He/She has _____________________% (in figure)______________ percent (in words) permanent physical impairment/blindness in relation to his/her__________________(part of body) as per guidelines(to be specified).

2.            The applicant has submitted the following document as proof of residence:-

Nature of Document	Date of Issue	Details of authority
		issuing certificate.

(Signature and Seal of Authorised Signatory of

notified Medical Authority)

Signature/Thumb impression of the person in whose favour disability certificate is issued.

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Annexure-VIII (FORM-III)

DISABILITY CERTIFICATE

(In Case of Multiple disabilities)

(NAME AND ADDRESS OF THE MEDICAL AUTHORTIY ISSUING THE

CERTIFICATE)

(See rule 4)

Recent PP size Attested

Photograph (showing face only) of the person with disability

Certificate No.							Date:
This	is	to	certify	that	I	have	carefully	examined

Shri/Smt/Kum____________Son/wife/daughter of Shri ______________________

Date of Birth ___ ___ ______Age _______________  years, male/Female________

(DD/MM/YY)

Registration    No.  _________________  permanent  resident  of  House  No.

________________ Ward/Village/Street ______________Post  Office__________

District___________State____________.

whose photograph is affixed above, and are satisfied that :

(A) He/She is a Case of Multiple Disability. His/her extent of permanent physical impairment/disability has been evaluated as per guidelines(to be specified) for the disabilities ticked below, and shown against the relevant disability in the table below:

S.No.	Disability	Affected		Diagnosis	Permanent physical
		part of			impairment/mental
		the body			disabilities (in %)
1.	Locomotor disability	@
2	Low vision	#
3.	Blindness	Both
		Eyes
4.	Hearing impairment	$
5.	Mental retardation	X
6.	Mental-illness	X

(B) In the light of the above, his/her over all permanent physical impairment as per guidelines ( to be specified) is as follows:-

In figure___________________ percent.

In words:_____________________________________________________ percent.

2.             This condition is progressive/non progressive/likely to improve/not likely to improve.

3.            Reassessment of disability is:

(i)            not necessary

Or

(ii)     is recommended/after ____________ years___________ months, and therefore this certificate shall be valid till _____ _____ ____________

(DD)  (MM) (YY)

@ e.g. Left/Right/both arms/Legs

#  e.g. Single eye/both eyes

$  e.g. Left/Right/both ears.

4.             The applicant has submitted the following document as proof of residence.

Nature of Document	Date of issue	Details of authority
		issuing certificate

5.            Signature and seal of the Medical Authority

Name and seal of Member

Name and seal of

Member

Name

and seal of the

Chairperson

Signature/Thumb

impression of the

person in whose

favour disability

certificate is

issued.

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Annexure-VIII (FORM-IV)

DISABILITY CERTIFICATE

(In case other than those mentioned in Forms II and III)

(NAME AND ADDRESS OF THE MEDICAL AUTHORTIY ISSUING THE

CERTIFICATE) (See rule 4)

Recent PP size Attested

Photograph (showing face only) of the person with disability

Certificate No.                                                                                    Date:

This     is   to   certify   that   I   have   carefully   examined   Shri/Smt/Kum

_______________Son/wife/daughter of Shri __________ Date of Birth________

(DD/MM/YY) Age _________years, male/Female___________ Registration No._____________ permanent resident of House No._____________________

Ward/Village/Street              _________               Post               Office_______________

District_____________State__________Whose photograph is affixed above, and an satisfied that he/She is a Case of _________________disability. His/her extent of percentage physical impairment/disability has been evaluated as per guidelines(to be specified) for the disabilities (to be specified) and is shown against the relevant disability in the table below:-

S.No	Disability	Affected	Diagnosis		Permanent physical
.		part of the			impairment/mental
		body			disabilities (in %)
1.	Locomotor disability	@
2	Low vision	#
3.	Blindness	Both Eyes
4.	Hearing impairment	$
5.	Mental retardation	X
6.	Mental-illness	X

(Please strike out the disabilities which are not applicable)

2.            The above condition is progress/non progress/likely to improve/not likely to improve.

3.            Reassessment of disability is:

(i)            not necessary

Or

(ii)         is recommended/after _______ years_______on this, and therefore this

certificate shall be valid till_________	________	_______
(DD)	(MM)	(YY)

@ e.g. Left/Right/both arms/Legs

# e.g. Single eye/both eyes $ e.g. Left/Right/both ears.

4.  The applicant has submitted the following document as proof of residence:

Nature of Document	Date of issue	Details of authority
		issuing certificate

(Authorised Signatory of notified Medical Authority

(Name and Seal) Countersigned

{ (Countersignature and seal of the CMO/Medical Superintendent /Head of Government Hospital, in case the

certificates issued by a medical authority who is not a permanent servant (with seal)}

Signature/Thumb impression of the person in whose favour disability certificate is issued.

Note: In case this certificate is issued by a medical authority who is not a government servant, it shall be valid only if countersigned by the Chief Medical Officer on the District.”