Form - I

Disability Certificate
(In cases of amputation or complete permanent paralysis of limbs and in cases of blindness)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY 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 am satisfied that:
1. he / she is a case of:
a. locomotor disability
b. blindness
(Please tick as applicable)
2. the diagnosis in his / her case is ______________________________________
3. 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).
4. 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
 FORM-VI
(As per RPD Act, 2016)
Certificate of Disability
(In cases of multiple disabilities)
{See Rule 18(1)}
(Name and Address of the Medical Authority issuing the Certificate)

Recent Passport
size Attested
Photograph
(Showing face
only)
Of the Person with
Disability

Certificate No.: Date :

This is to certify that we have carefully examined Shri/Smt/Ms.
_______________________________, 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 am 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 (_____________
number and date of issue of the guidelines to be specified) for the disabilities ticked
below, and is shown against the relevant disability in the table below:
Sr. Disability Affected Diagnosis Permanent Physical
No. Part of Impairment / Mental
Body Disability (in %)
1 Locomotor 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 & Language
disability
12 Intellectual disability
13 Specific learning
disability
14 Autism Spectrum
Disorder
15 Mental Illness
16 Chronic Neurological
Conditions
 Sr. Disability Affected Diagnosis Permanent Physical
No. Part of Impairment / Mental
Body Disability (in %)
17 Multiple Sclerosis
18 Parkinson's disease
19 Haemophilia
20 Thalassemia
21 Sickle Cell disease

@ e.g. Left / Right / Both Arms / Legs

# e.g. Single Eye
* e.g. Left / Right / Both Ears

(B) In the light of the above, his/her overall permanent physical impairment as per
guidelines (_________ number and date of issue of the guidelines to be specified),
is as follows:
(C) In figures : __________ percent
(D) 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).
4. The applicant has submitted the following document as proof of residence:
Name of Document Date of Issue Details of Authority issuing
Certificate

5. Signature and Seal of the Medical Authority

Name & Seal of Member Name & Seal of Member Name & Seal of the
Chairperson

Signature / thumb impression

of the person in whose favour
certificate of disability is
issued
Form - III

Disability Certificate
(In cases other than those mentioned in Forms I and VI)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY 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 are satisfied that he / she is a case of disability.
1. His / her extent of percentage of physical impairment / disability has been evaluated as per
guidelines (to be specified) and is shown against the relevant disability in the table below:

S. No. Disability Affected Part of Diagnosis Permanent physical impairment / mental

Body disability (in %)

1 Locomotor @
disability

2 Low vision #

3 Blindness Both eyes

4 Hearing £
impairment

5 Mental
retardation

6 Mental‐illness

@ ‐ e.g. Left / Right / both arms / legs

# ‐ e.g. Single eye / both eyes
£ ‐ e.g. Left / Right / both ears
(Please strike out the disabilities which are not applicable.)
 2. The above condition is progressive / non‐progressive / likely to improve / not likely to improve.
3. Reassessment of disability is:
a. not necessary
b. is recommended / after _________ years ________ months, and therefore this certificate shall
be valid till (DD / MM / YY) ___________________
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 certificate is issued by a medical authority who is not a government 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 of the District.
Note: The principal rules were published in the Gazette of India vide notification number S.O. 908(E), dated
the 31st December, 1996.
)RUPDWRI0HGLFDO&HUWLILFDWH5HSRUWWR%H3URGXFHGE\'\VOH[LF&DQGLGDWH

{To be obtained from any Dyslexia Association*}

Date: ________________
PSYCHO‐EDUCATION EVALUATION REPORT
Recent PP size
Name of the candidate:
Attested
Date of Birth: Photograph
(showing face
Registration in the Dyslexia Assn. (date / number): only) of the
person with
Name of the Father / Mother / Guardian: disability

Name / address and Regn. No. of the Dyslexia Association:

Physical & Neurologic Assessment: [ ]
Psychological Assessment: [ ]
WISC Verbal IQ:
Performance IQ:
Full Scale IQ:
Interpretation: [ ]
Educational Assessment: [ ]
Certified that:
1. The condition of handicap is: MILD / MODERATE / SEVERE (tick whichever is applicable)**
2. The disability is PERMANENT in nature.
*Some Dyslexia Associations:
1. Dyslexia Trust of Kolkatta, Divya Jalan, Aruna Bhaskar 3, Dover Park, Kolkata – 700019
2. Dyslexia Association Of Andhra Pradesh (DAAP), 3‐4‐494 / 1,1st Floor, Macherla Gastrology
Hospital, Reddy College Road, Barkatpura, Hyderabad, Telangana, 500027
3. Madras Dyslexia Association, 94 Park View, 1st Floor, G.N. Chetty Road, T. Nagar, Chennai – 600017
4. Maharashtra Dyslexia Association, 003, Amit Park Bldg, L J Road, Deonar, Mumbai 400088
5. The Dyslexia Association of India, MZ‐47, The Center Stage Mall, Plot No 01, Block L, Sector 18,
NOIDA 201303
**Learning Disability is a permanent developmental disorder. Currently there are no standard approved
methods to quantify the disorder. However, the method of diagnosis is based on significant impairment in
academic achievement. To avail the benefit of relaxed norm under PwD category, the candidate must come
under SEVERE category.

Name of the certifying official:

Seal: