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Proforma to be filled by the medical board in case of PH candidate.

CIVIL SERVICES EXAMINATION, 2017

Full Name
(in Block
Letters)
Roll No.
PHOTO
Date of Medical Examination
(To be affixed by the
candidate before medical
Place of Medical examination – AIIMS, New Delhi board)

FORM OF CERTIFICATE TO BE PRODUCED BY

PHYSICALLY HANDICAPPED CANDIDATES

I, Dr. ………………………………………. Regn. No. ………… have examined

Shri/Miss/Mrs.……………………………………….. (Roll No………………. CSE-2017)
whose particulars are given below and hereby certify that she / he is a permanent
physically handicapped person of the following category which is covered by the Rules of
the Civil Services Examination, 2017.

S. No. Disability Functional Classification [FC]

(Please tick and also write in point (Please tick and also write in point no. 2)
no. 2)
1 Locomotor Disability and Cerebral One Arm (OA)
2 Palsy (LDCP) One leg (OL)
3 Both Arms (BA)
4 Both Hands (BH)
5 Muscular Weakness (MW)
6 One Arm One Leg (OAL)
7 Both Legs and Arms (BLA)
8 Both Legs One Arm (BLOA)
9 Both Legs (BL)
10 Visual Impairment (VI) Blind (B)
11 Low Vision (LV)
12 Hearing Impairment (HI) Partially Deaf (PD)
13 Fully Deaf (FD)
(Delete the category whichever is not applicable)
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2. Shri/Ms……………………………………………………has found to be a
………………..[LDCP/VI/HI] category candidate. He/she has a permanent disability of
/in…………………………………[FC]. The percentage of disability in his/her case is
…………………..
(…………………………………………………………………………………….in words also).

3. Shri/Miss/Mrs. …………………………… meets the following physical requirement for

discharge of his / her duties:

Please write Yes/No whichever is applicable within ( )

All fields are mandatory.

(1) S - Work performed by sitting (on bench or chair). ( )

(2) ST - Work performed by standing. ( )

(3) W - Work performed by walking. ( )

(4) SE - Work performed by seeing. ( )

(5) H - Work performed by hearing / speaking. ( )

(6) RW - Work performed by reading and writing. ( )

(7) C - Work performed by communication. ( )

(8) MF - Work performed by manipulating (with Fingers). ( )

(9) PP - Work performed by pulling and pushing. ( )

(10) L - Work performed by lifting. ( )

(11) KC - Work performed by kneeling and crouching. ( )

(12) BN - Work performed by bending. ( )

4. Examination of PH Category Candidate by Central Standing Medical Board. Please

fill the proforma enclosed with this medical examination form mandatorily.
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4.1. Examination of Locomotor Disability Cerebral Palsy (LDCP) Candidates:

S. No. Parameters Calculation of % age of Overall % age of

disability disability

4.2. Examination of Visually Impaired (VI) Candidates:

S. No. Parameters Calculation of % age of Overall % age of

disability disability

4.3. Examination of Hearing Impaired (HI) Candidates:

S. No. Parameters Calculation of % age of Overall % age of

disability disability

Signature of Surgeon/Medical Officer

Designation …………………….

Office Stamp………………………..
……………………….
Signature of Candidate Address………………………………...