Off ice district state whose photograph is affixed

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Ward/Village/Street…………………………..Post Off ice…………………… District…………………………… State……………, whose photograph is affixed above, and am satisfied that: (A) He/she is a caseof: *Locomotor Disability *Dwarfis *Blindness (Please tick as applicable) (B) The diagnosis in his/her case is…………………………………..……………. (1) He/She has ……………% (in figure)…………….………….…. percent (in words) permanent locomotor disability/dwarfism/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 signature Signature and Seal of Authorized Signatory of notified Medical Authority ) Recent PP Size Attested Photograph (Showing face only) of the Person with disability Signature/Thumb impression of the person in whose favour disability certificate is issued
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Page 26 of 35 PROFORMA-III-B FORM-VII CERTIFICATE OF DISABILITY (IN CASES OF MULTIPLE DISABILITIES) (NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE) Certificate No.: ………………………………… Date:………………………. 1. This is to certify that we have carefully examined Shri/Smt./Kum ……………………………………………..…………….. son/wife/daughter of Shri……………………………… Date of Birth…………………… (DD/MM/YYYY) Age ………….years, Male/Female……………………Registration No. …………… ......... Permanent Resident of House No. ….….. Ward/Village/Street ……………….……………..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 Part of Body Diagnosis Permanent Physical Impairment/ Mental Disability (in%) 1. Locomotors Disability @ 2. Muscular Dystrophy 3. Leprosy cured 4. Dwarfism 5. Cerebral Palsy 6. Acid attack Victim 7. Low Vision # 8. Blindness # 9. Deaf £ 10. Hard of Hearing £ 11. Speech and Language disability 12. Intellectual Disability 13. Specific Learning Disability 14. Autism Spectrum Disorder 15. Mental-illness 16. Chronic Neurological Conditions 17. Multiple Sclerosis 18. Parkinson ’s Disease 19. Hemophilia 20. Thalassemia 21. Sickle Cell disease (B)In the light of the above, his/her over all permanent physical impairment as per guidelines (to be specified), is as follows: In figures: ………………………..percent In words: …………………………………………percent 2. Thisconditionisprogressive/non-progressive/likelytoimprove/notlikelytoimprove. 3. Reassessment of disability is: i) Not necessary, Or ii) is recommended/after ……………….Year ……………………months, and therefore this certificate shall be validtill …………………………………………… (DD/MM/YYYY) @ e.g. Left/Right/both arms/legs; # e.g. Single eye/both eyes; £e.g. Left/Right/both ears Recent PP Size Attested Photograph (Showing face only) of the Person with disability
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