8/11/2019 Proforma for Ph Certificate

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Format for Physically Challenged (PH) Certificate

(To be obtained by the candidate)

(To be filled by Medical Board notified under PWD Act)

Certificate No:

Date:

This is to certify that Mr./Ms______________________________________________________________ son /

daughter of Mr./Mrs._____________________________________________________ Age

______________male/female, Registration No._____________________________is a case of

______________________________. He/She is physically disabled/visual disabled/speech and hearing

disabled/having mental retardation/leprosy cured and has %(______________________per cent) permanent

(physical impairment/visual impairment/speech and hearing impairment etc.) in relation to his/her

__________________________________________.

Note:

This condition is progressive/not progressive/likely to improve/not likely to improve*.

1. Re-assessment is not recommended/ is recommended after a period of___________months/years*.

(*Strike out whichever is not applicable)

Signature of Dr. Signature of Dr. Signature of Dr.

Name of Dr. Name of Dr. Name of Dr.

Specialization Specialization Specialization

Seal with Degree Seal with Degree Seal with Degree

(Member, Medical Board) (Member, Medical Board) (Member, Medical Board)

Signature/Thumb impression of Patient

Countersigned by the

Medical Superintendent/CMO/Head of Hospital (with seal)

Information/Guidelines

1. Disabilit

y certificate shall be issued by Medical Board of at least three doctors duly constituted by the State or Central

government under PWD Act.(One of the members of the Board should be the specialist in the particular field forassessing Locomotor, Visual disability, Hearing and Speech disability, Mental disorder and Leprosy cured)

2. If

disability is likely to decrease (temporary type) then, the certificate should be valid up to September 15, 2011.

3. For candidature under physically challenged category, candidates only with a minimum of 40% disability is required

subject to the condition that the candidate is capable of carrying out all activities related to theory and practical

work as applicable to various programmes without any special concessions and exemptions.

4. The Medical Officer of NIT Rourkela may assess the Physically Challenged (PH) certificate and the decision of the

Medical Officer is final and binding on the candidate.

Affix here recent

Photograph showing

the disability duly

attested by Medical

Superintendent/CMO/Head of

Hospital (with seal)

8/11/2019 Proforma for Ph Certificate

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FORM FOR PHYSICALLY DISABLED CATEGORY

I, Dr. _________________________ Regn. No. _______________ examined Shri/Smt./Kum. ____________________ whoseparticulars 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) PB-Partially Blind

(x)

PD-Partially Deaf

(xi)

D-Deaf

(xii) LV-Low Vision

(Delete the category whichever is not applicable)

2. The percentage of disability in his/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 bodilyinfirmity 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) Identification Marks _______________________________(iv) Sex ______________________________(v) Age ______________________________

Signature of Surgeon/Medical OfficeDesignation________________

Signature of Candidate

Office Stamp ________________Address ____________________

Note: The disability certificate should be issued by a Govt. Hospital