- ::_::.lr1':x , .

Forrvr - lV

Disability Certificate 'a

(ln cases other than those mentioned in Forms ll and lll)(see rule 4)

INDIRA GANDHI GOVEFTNMENT GENER/AL HOSPITALAND PO$T GRADUATE INSTITUTE, PUDUCHERRY

ANDDISTRICT DISA.BLED REI.IABILITATION CENTER, PCDW & DI\P

PUDUGHERRY

ertificate Nq. 14-]L

ate: 13"B tS

ris is to certify that I have carefully examined

:rri/Smt./Kum. V ' GnqAT H RT-

rn/wife/daughter of Shri

ate of Birth(DD) (MM) (YY)

ELU

Age 22- Years, rnaJe/femalen

l-4nn{,1!-

permanent resident of Houselegistration No.

o.. , t.lB . WardA/ill

ost Office District State P', A,tAaVttt-. //U

those photograph is affixed above,, and am satisfied that *iShe is a Case of

\/ri,.r+,J Oisability. His/her extent of percent€rge physical lmpairmenV

sability has been evaluated as per guidelines (to be specified) and is shourn against the relevant

sability in the table below.

L-\, t.t^U-'\ ^ ,\<; ,i-L't7 -Vlr \]

-"/

ilr, !:i--,1.

i:, a .i rjl

sr.No

DisabilityAffected Part

of Eody Diagnosis

PermanentPhysical

impairment/mental

disabilitY(in%)

1. Locomotor disabilitY

z-. Low vision

aJ. Blindness tso*h Eyes

V ^ a,{L/o"--6r'/ao

,,{"{rrn*A*r,t;e

T Cr-V'-

a.,- ,

/:2%

4. Hearing irnpiirment

Mental retardation X

Mental-illness

\

a,

.rove coni!i:cn is c,rogressi'zei'l-icn- pl-cgressi,rei iikeiy lo improvei nct lii<el5u

r?eassessrnent of disabiiity is :

(i) not necessary,

OY

(ii) is recommended/afier_years_ months, and iherefore this

certificate shall be valid tili

(DD) (MM) (YY)

e. g. Left/Right/both armsilegs

e"g Single eyelboth eyes

e. g. LefVRighUboth ears

The applicant has submitied the foiiowing document

,a(4

t

{+- as pi-oof cf i-esicience:

n.L.v)( b-?d,-

Ce-^,.r., .|:"-<l-q +-J*.LGo u.i . .}-..1*c,'

Nature of Document

[<,.e6- C.,r.A

^lL ' D Lar.d.

A a-d.I*- cnr\d

Detaiis of author"iiy lssuing i

Ceilincaie

)a-pr 4

lAuthonised Signatory of Not[fied &rleciical Auttrority){Neine a.rr$ Seal)

, i--, : r":'-:

f t1.:.i\ ,.,,:,-i .: t: ::.. ..-ri. ii-':_t::,,! . i". ._ -i L ,_. i

" :i--i'.('.ii i' ,,'r i , r.- , ir.,.

Goes erte'rs*gs?edt-,t _

'ra:tl{cdfcd SuPcrintcndcnt

;jJilr&ti.eirrs.sgftqefrS ancj seai of iheturd Fc$f;F$frddtif#t:S u pe ri nten e n VH ead ofAl&(!trrt'ffiVEinment Hospital, in case the

certificate 'is issued by a medr.calauthor-it-v who is not a government

'servant (with seal))

a medical authority vuho is nci a govei-nment servant, it shall

Medical Officer of the District."

i.n ttrc"Gazette of inciia viCe notificaiicn number *q.C 908(E),

$ignature/Thumbimpression of theperson in whosefavour disability

is issued

hrlote : ln case this certificate is issued byr

be vai{d only if countersigned by the Chief

Note : The principal r-ules wer.e published

dated the 31"'Decembe6 1996.

flffiw#

\f D 4-"-\ ^ Ixrrt\ tr'\'5\w\-

u+). ' .

( " Form-tV

. Disability Certificate(ln cases other than those mentioned in Forms Il and lll)

INDIRA GANDHI GOVERNMENT GENERAL HOSPITALAND POST GRADUATE INSTITUTE, PUDUGHERRY :

AND.iDISTRICT DISABLED REI.IABILITATTON CENTER, PCDW & DAP

PUDUCHERRY

CertificateNo. l20lDate: Lq tt t(

This is to certify that I have carefully examined

shri,Smt./Kr.,n1. 3 ,4 AJf fif D u

Son/wife/rjaughter of Shri S t-l,a n: f"l U & n tt

Date of airrh 09 o 4 Y3L Age ) I years, mate/fen+a"{e(DD) (MM) (YY)

Registration No._- lzot f zotf permaneqt resident of House

'.') hNo. .1b WardA/iltage/Street.

Naala-

Post Office State

whose photograph is affixe<i above, and am satisfied that He/she is a case of

\,/'. 0 .. .V-L!-t*t-(' disability. His/her extent of percentage physical lmpairmenV

disability has been evaluated as per guidelines (to be specified) and is shown against the relevant

disability in the table below.

I)r.

.. I IlF rI l-EL3 'cflr0''.--- . Ita- td..Gta--

)

*

st.No.

Disability

i

Affected Partof Body Diagnosis

PermanentPhyslcat

impalrmont/m€ntal

disablllty(in%)

1 Locomotor disability

:

2.

l:

Low vision

.)J. Blindness Both Eyes

'v.(- 4r" Rr,*'-^9'' I h){ ?,"gu}

' /1 .2't/L 5 Cf€ t";n-l--r-1

-r"6/5,

4 Hearing impairmenl

5. Mental retardation x

o. Mental-illness x

,-\-

The abCrre r:ondition is progressivei non- progressive/ likely to improve/ not likely

3. Reassessment of disability

(i) not necessary,

or

(ii) is recommended/aft er_years--certificate shall be valid till

(DD) (MM) (YY)

e.g. Left/RighUboth arms/legs

e.g,LefURighUboth ears ,

The aBplicant has submitted the following document as proof of resirjence:-

months, and therefore this

@

+lt

f,

4.

(Authorised Sigrratory of Notified Medical AuthorityiDr. R tr!!lr{,Av lr.r,u,o,o,s,$$flarne and seal}

SFECtALtSy c?.I :

HEAO OF THE OEPT. OP}iTHAL

,o oo Jinuli'lll'"1 n",,r.

i -.dt"\,1 --.*Fi

xedicil Superintendentlodirr Grndhl Go4. Gcnarrl Hotprrel- .And torl Gndrrtr lnrrtstt.. - thducfiem. -'

Countersigned:

,{Countersignature and seal of theCMO/Medical SuperintenenVHead ofGovemment Hospital, in case the

rcertificate is issued by a medicalauthority who is not a governmentservant (with seal)) :

Note : ln ca$e this certificate is issued by a medical authority who is not a government senzant it shati

be vaild only iT countersigned by the chief Medical officer of the District.":l

Note : The principal rules were'published in the Gazette of lndia vide notification number S"O goe(E),

:

Nature of Document Date of lssueDetails of authonty lssuing

Certificate

Df+ o6 Cruil ,L*xS,-

)

:,i!'r!1.1';! ir:.]:...:1.,:",. 1

. i psPp.--ta2'G[E-10,000 cps (G',i

DEPARTMENT OI. CRTHOPAEDICS

GOVERNMENI' GENERAL HOSPITAL, PONDICIIE,RRY

nrrPi()l("r r tot L:46C *, ,,t-o

: :'!|-', :i,:.,:;;:4,2 !i:,_

I'J<.r . . ijutcd

\i, ,, i '\CIRTiF!CATE--'; F;

z fl-Xf; iq, ' 'MEDICA.L

i . I'{arnc ol" titc ltpplicant

,1. /\1y.r 1111d $s^

.1 . lrirtlrer''s i l'Iuobli)idjs nanr,l

.i. I'J;rtur e ol' ciisabiliry

,'ittlull.tllc $1" l.rPPliclrut

'l rr

'l'h i r uf"i"rnt,/Sc tv i

.. ---*n--h-- Ln'.q=o-otp-Fr4,r+--_.r

,(ipecr;,{ist Cnrctc-l/Il irr olrhopactlict irave ihir l]i{ O Ul'iO6,l. day ol'

. rraurineri thr: applicant rylrose partictilars are given..belc'rrv aud thal hc/sLe laUs uudcr thc catcg'rry

,rl (irtrrrrpirotliurrlly l.landicappcd persoo.

-(c^t G G,vt .G hJ t' i t.'' L

-S- .-. years Irlale / ,r^orY7

L-dtq,,o,a'.., I l, ,1r'' i

...^ , ), i.-

Dt6/: /. .:

,- .t / ..-.-( .

,!.4 .l , . ',i,.-,.-.t.. :t.., L./ u a' . "

-i ) rl{.i,-, ,i

',,.l:,;llr.tr{:rlFr]isatrility(Asl)cf,rlifl..lIan.Ui1I,lQrL)rtltotrcadic Surgeons. lt1 evatuatlDgpet'rnahent physictt iurpairrnent) I

15. .r\ny spcciftc t'ccolpnrenditticlns ":

t/,

ilt. {Jltliriitaxrlicr',. , ,

p ".r.-. d.ty

DEp ARlldE].i-t oF 0III_OIAEDIC S, co. \ruR]\rMENT GENERAIHosprrr'r, pci.,DIClIERRy AlrD Dldrnicr crN.aii-ror i#'DISABLITY, D. S.W., POJ,.{DICTIERRY.

},ffi DICAI" CERfiFICATE FOR ORTIIOPADICAILYFIANDIC.IJPPED PBSONS

INorGIrD/c.*,.hctce*tr2.n "f tO7 f"6 ,

Certifi,:ii tli;,.t, I D:..fr......N*r*t**.Ktr+a*6.:.Grade...- r

orthopaedir,-s Speciaust havy this a"y "i _z_ [r-=,. = . ;8.:...:;;;;il ;;;l#

-

whose 0artii)'-]iars are given below *o tn t lysne falls rmder the category of orthopae.licaliy

1 NamecNlneairylicant H . Me.ualAf<S'ttMl'2. Agc and Sex : l-3 _ F+*olp_

'3H:;,;lll#Tlsltrrhemanuarror /

fr,h4l,rfurktfu /"4

Govt. Gene.ral !-1bs;rrla I

,,

Pondi.h*''y

liiri;;

sii"

B36d; .21 . 2. Zp6lo .

wahrating pei.rna*ent plrysicat .irupairment):

,,{.r +, sPerifi c reccn:mendations

'.1;l{:,pp-,urpcse cf issue of certificate

9. Identifica.don Ir,IarLr of ttre applicant

rfucry_I%<fu Mn

tul

''ta

/.neq /tuwLSignature of the Specialist in Ortbr7pa*dics

Dr K i.iAi.lD fi.ir.,. lt., j,! 1 ,, :t .i I . o orrhlSIrlr-r.tirrl. . li,rr ti. r.t,Cs)R-cil i.lo: _lft .._; (T.::t.ri llirrtu)

Gol, 1 Gerr....:; rioslritci

. Pondicnerry.

:1.4),

_u(

HSignanre of appric"rnt

To

i -'.i. ,

Nr,orca'-YsUIint,;i#lildir.i 6.rrr.lli (,t'vl Iiirirri. ]l::

i'irrri f'uri Lr ;i{l.,ir i il;!:l;''L

EmsrGn*Hs

!

Ij. Mc, l.' ^

ir it< '-----'

DEP,{RTMEI.IT OF OR.THOPAEDICS, COVERNMEI'{T GENERAL HOSPITAL'

PUDUCI{ERRY AI\D DISTRICT CENTRE FORTHE DiSABILITY, D.S'W.'PUDUC}fiRRY.

MEDiCAI, CER.TIFICATE FCR. ORTHOPAEDICALTYHANDICAPPED PtrRSONS *r*.tt

No. GHP/odho/certi/ *S lg 6 . n"t" f h I,t

Certified that, i, or..r4j..,//t A.l/Ot /Q*-.....Grade...-2. ..........orthopaedics

Specialisthavethis aayaf....?:...-*..../.Q..,.............examinedtheapplicantWhoseparticularsare

given below and that he/she falls under the category of orthopaedicatly handicapped persons.

6;,unn2"/,

,r4 Sz.n or> n4^n M *

Speciallol Gr. I {Orthc Pardir:s}H*g hlo : 417U9

lndlra Brndhl Govt. General l{osnitalAnri Pcit Gr3GLHIg lnstltute, Puillcherry,

?! J1. Name of the applicant

2. Age and Sex

3. Father's or Husnand's Name

4. Address

5. Nature of disabilitY

6. Extent of disability (as per the manual forOrthopaedically surgeons in evaluatingpermanent physical imPairment)

7. Any specific recommendations

8. Purpose of issue of certificate

L ldentification Marks of the applicant

P O",U*r"t -Signature of applicant

To

.:171$ly; $;1nflfl

nnd FnEt GEdu*to

5. :lde ntiiiqation,,,

,'. "1.1..,':il::,:

t :,. : t'.::-,_, .,,,,:.t, ,.t.,.r:

lppliqan!. -.::

.,','r,r:. ,';?,'i'

- : ,.,i.:a 1:: ,tii,..

.,t: r : .t :.i:4 J.l,i :lj.t:tr:. ,.

j.. -. . ::-:,:|,, ''--:

n:irks-, of,..tirc-.. .;'. .i.rji

5.

7.

C.ttcgoqy . TYPe -;o{ ,

lmpg|trg9lDQ.,f9vel Speech .r

disdmination, ,:-.

Percenlagc rol,imp.airlnent,

:'.dB,.26 :to:40 :;',.i.dB,:in;bettor ear'.a :.,:-: '. : ". .

,80.1o,,100,2; .,,,

.,jn ,:b€tter.i:ear

' 'ir l '. :,,i!'Less tlianil40 %

rrL.7-1ii1 rr:rirl:,../.j.il:n:r::r.::,1:r:::' 1 -

':i'll l ::il:.ji:'rii'

JIIL:i'ili,':.: ':: :.:i:jr'::

,4i rb 60 dll in ,

better ear I :

,..,6Lto 70 dB .

r, heuring impairineut .

in better ear

7l.to 90 dB

'5o'totgoglr, . .' t. -'

'ln.tettei'hi ,, ''' t;i':'i.: ,,,:' .,'.i: - .' .

,

:40 to, 5{:,'1,',., ,

itr "k!!!i{.::qr :; . .,

' -'i ll': :":: _':': :

i,... ' :.:ji.. -,.":-::,.,.. . .1.

'fl.i(,to.'.r --, ::": ' t>'1

:.:,i.; i'i:: ::'1 '' ': ; ' ' -:

'j:',:.,i|'l% \o lM11:.,'..'j ,.,-::i:r : ,- 'r::1. a'it i-:i.!:.:, ,'::1, ..

:,:ir:i',:.ii: r'a.li,:, r _:. . :r:'."

:;-.1:. : ' -

.;, 1U))/;' . '

::.,1."-.i i ri. ".'

I ess than :4l)."11'",.1in .bctter

car' :.^ :,

ri:91 dB, an<I, above iu .

'"'bctter garlto heariogVery ,poor,. .

discrruiirgdog

clnq{ydi yri,+u[tuthandicapped .percon under Cste6ory No-i

, A'nd-'*, &41 r16[

?t.r

,ltpri,\,1Wyrl'

'tliira[,'rnt.1$eivi

a FauCff,r tY;