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Tqi-fi srfBfrqq, rss+ (uem{vhfto) sfi Gr$Ifr-d c-+w do' *-4T) (sl-d{fud qrfrsf. 3r-Sqfud s.I urffit dq srq s'.il orner"r) (ff{Nrr) eilUfrqq; zooj sriT cft-{Qrfro frtqr rrrlr +sI (st-{qfr-d qrfrqt, eT-{qftrd wc qrfut eils 3r-q rq sto-s !-eyr s.rt ftrt erner"r) (H{Nrq) erftfrqq, 2002 Er{r ffiD=d 01 're t. snorfud c-S t t {d-d qror-ftar o1 ffi-dy s{ q,1 q-q& d ftri woa qrffi-o' 3ils e are r"qd qr {fl-S B{k6 ;r& nen q-i-d srfl u=ffir oiEfrqq, rssz ti qQn f4trf, W ftqr srtr6 wqfu.ft r& fu vmc (S{Tr t d t */4rfr/gqTfr TETFI * @ atr t ............... d ftri fi{ N t denlorerqr s"FFr cRsn B-f,r e-i{r d r d . ft-{f6 wr IIr[ q( 6I ffiorff Z eftftm Mffi Z qrq "fl-EI Rr8 qftnfg 7 trirmr q&n*e Z orsfi-irflt { ' -'- "-t'.-' -''.-'i1i -: J-., l: -" '' "' lili soso d ff{mtrit d n-flur-wr CERTIFICATE FOR PHYSICALLY HANDICAP OF U.P. NAME & ADDRESS OF T}IE INSTITUTE/HOSPITAL CERTIFICATE No. DISABILITY CERTIFICATE This is certified that Shri/Smt./Kum. Son/Wife/Daughter of Sex... Shri . .. age ..... identification mark (S) is suffering from permanent disability of following category. Locomotor of cerebral palsy BL-Both legs affected but not arTns. BA-Both arms affected impaired reach Weakness of grip A. (i) (ii) (iiD (iv) BLA-Both legs and both arms affected OL-One leg affected (right or left) (a) (b) (c) Impaired reach Weakness of grip Ataxic OA-One arm affected Impaired reach Weakness of grip Ataxic BH-Stiff back and hips (Cannot sit or stoop) (vii) MW-Muscular weakness and limited physical endurance. Blindness or Low vision. (v) (vi) B. (a) (b) (i) (iD (a) (b) (c) B-Blind PB-Partially Blind Hearing Impairment: D-Deaf PD-Parlially Deaf (Delete the category whichever is not applicable) The condition is progressive/non-progressive/likely to improve/not likely to improve. Re-assess of the case is not recommended/is recommended after a period of ... .....months. Percentage of disability in his/her case . . . .. percent. C. (D (ii) 2. 3. 4. .....year. is Shri/Smt.a(um. Meets the following physical requirements discharge of his/her duties: F-can perform work by manipulating (with (i) (ii) (iii) (iv) PP-can perform work by pulling and L-can perform work by (vi) (vii) sitting. ST- can perform work by standing. lifting. pushing. KC-can perform work by kneeling and S-can perform work by fingers.) YesA.{o YesA.{o YesA.{o couching. YesA{o YesA.lo YesA.[o (viii) (ix) (x) (xi) W- can perform work by walking. SE-can perform work by seeing. H- can perform work by hearing/speaking. RW-can perform work by reading and writing. (Dr... (Dr. Member Medical Board ......) Member Medical Board YesA.{o YesA.{o YesA.{o YesA.{o (Dr... .........) Chairperson Medical Board Countersigned by the Medical Superintendent/ cM9/HQ Hospital (with seal) Strike out which is not applicable. 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