sar wee 3 ara ftes of & fey onfe sao a @gafad onftal, age oonftat stk aa fos at 3 fag arent ) siffrry, 1994 (Gereeifra) a orayi—va & orerfer aTraT wre al ae A wenfore fear ore & fee ait / strc / Gare... Yalan afffiat 1994 ede aM cher RP SAMA ee @gafaa unftat, angyfir oeonftat site amr fies ait a fery ameet) (Hehe) afer, 2001 grr ufteenfte fear war @ yd Gt ou ctw Var Grate unital, aqyfir oronftat sie amr flee aif d fey ae) afar, 2002 eer deter a wet 8, B areata ae 81 gad afar @ Prana ast a woot affe ara ons are wd ar gee afte Ae 2 am ste oe eaaX afOfiay, 1957 4 aenfafet ge ven S afte a water a ae 81ae Aer Teepe oT rer sTAPeer oro Fee OMAN TTT ll tale aprRE/ TER APRS TEA ora Ser ah afbrege, aR ae By rer ar Sear setter |TE FOR ‘SICALL' ICAPPED OF U.P. NAME & ADDRESS OF THE INSTITUTE/HOSPITAL, Certificate No... DISABILITY CERTIFICATE =n E ofthe emia showing the allested bythe Chaimerson ofthe Medics osc ‘This is contted that ShrvSmukum. sonwife/daughter Of SHI... sex ‘dentification mark (8)... A. Locomotor or carebral palsy: (1) BL.Both legs affected but not arms. (H) BA-Both arms affected {@) Impaired reach (b) Weakness of grip (itl) BLA-Both fogs and both arms affected (Iv) OL-One leg affected (right oF let) {8) Impaired reach {b) Weakness of grip (6) Ataxic {v) OA-One arm affected () Impaired reach (©) Weakness of grip (0) Alaxic (vi) BH. Stiff back and hips (Cannot sit or stoop) (vil) MW-Musculer weakness and limited physical endurance, B. Blindness or Low Vision: () B-Bling (i) PB-Partlaly Bling Hearing impaiiment: () D-Deat (i) PO-Patiialy Dest {Dolete the category whichever Is not applicable) 2. This condition is progressive/non-progressiverikely to impro recommendediisrecommended after 2 period of... 3. Percentage of disablity in his/her case is 4. Sh/Smtkum, . age.. — ‘rom permanent disabitty of following category: 18 suffering /nat tikely to Improve. Re-assessn of this case is not months, percent sereor MWS the following physical requirements discharge of his/her duties: () F-can perform work by manipulating with tigers. YesiNo (\) PP-can perform work by pulling and pushing. YesiNo (i) L-can peiforin work by iting. YesNo (') KG-can perform work by kneeling and crouching, YesiNo {¥) B-can perform work by bending, YesiNo (vi) S-can perform work by sitting YesiNo 7 (vil) ST-can perfor work by standing. Yes/No (vil) W-can perform work by walking ‘YesiNo (tx) SE-can perfor work by seeing, YesiNo (¥) H-can perform work by hearing/speaking YesiNo (xi) RW-can perform work by reading and writing. ‘YesiNo (or. ) (or, ) | Member ‘Member Chairperson ‘Medical Board Medical Board Medical Board a Countersignedbythe Medical Superintancery MOMMA Hospital (th seanSax wee cle Va EMRE wa a Aewcin, wise da Saal S ans ak aad Sai & fey orem) affiaH, 1993 (werent) + srpAR Kaa vio Sart S onfher WAI—wa wT ITA | are venfore four orar & fer sit/ after 1 TET rene soe TR eo! oe a ee itr sare ihe anBion eh spat ARS re! aren) RIP 1993} anpE waiam Wars Bart & aie s/s /Gare (onfFre)..... a/R a (gr on ga GBT IG) TA GH ee (Rae sera aftaa) seit «REM, 1999 (aemizifita) & merit & ampere ve sf / sir (Kaiser dart Warh). % onftrr &1