Government of West Bengal Health & Family Welfare Department (PHP Branch) ‘Swasthya Bhawan, GN-29, Sector-V, Bidhannagar, Kolkata-700 09] No. 289-HE/O/PHP/IR-05/2017 29.8.2018 ORDER Ministry of Social Justice and Empowerment of Petsons with Disabilities, Government of India has enacted the Rights of the Persons with Disabilities Act, 2016 and thereafier has notified guidelines for assessment and certification of specified disabilities included under Rights of the Persons with Disabilities Act, 2016 vide Notification No. $.0. 76(E) dated 4.1,2018. ‘Now, in pursuance of Section 57 of the said Act, the certifying authorities and the jurisdiction within which such certifying authorities shall perform their certification functions are mentioned hereunder. ies at different tier/hospitals will be as 1, The certification of different categories of dis follows: Tier/Level of Si | Categories of Speeified Disability ssn No. | Disability ‘Medical Disability Certification Board 1 2 3 4 5 1) Chairperson of the Board -Medical | Superintendent or M.S.V. Director. ii). Specialist in Orthopedics. iii) Specialist in Physical Medicine and Rehabilitation jv) One or two more specialists as nominated by CMOH/ Principal Director as per the condition ofthe | person with disability. 8) Locomotor disability ») Leprosy cured person Locomotor ©) Cerebral palsy SDH, SGH,DH, Disabilities ) Dwarfism Medical college ©) Muscular dystrophy 4) Acid attack vietims ') Chairperson of the Board -Medical Superintendent or M.S.V.P / Director ii). Eye specialist. iii) One specialist as nominated by CMOH/ Principal) Director as per the condition of the person with disability. SDH, SGH,DH, 2 | Visual ‘) Blindness Medical college impairment |b) Low vision i) Chairperson of the Board -Medical Hearing 2) Deafness Impairment & — | b) Hard of hearing SDH, SGH,DH, | SuPerinendent/ MS.V.P 3 Speen cae o,sieee ‘end Language | Medical college Sr sect Disability iif) One specialist as nominated by CMOH/ Principal! Director as perThe condition of the person speech therapist. i) Chairperson of the Board - Medical Superintendent / M.S.V.P / Director. ii), Pediatrician for childhood chronic b) Rest of the districts will be covered by Nil Medical College and Hospital District Hospital, | neurological condition / oad ; : Medical college, | psychiatrist for mental Cire eal |) Multiple ssleels | specialized cee | ins de to chron | oma ') Parkinson's dseese | ie, Bangur institute | neurological condition! of Neurosciences, | neurologist for chronic Kolkata neurological conditions | without mental iliness. ii) Specialist for certifying locomotors disability. iv) Trained psychologist (clinical or rehabilitation) to administer 1Q test | a) Medicat College, Kolkata will eover the following distriets- ’) Hooghly 19 sass |) charpeson ote 1 et | Board = MSN.P /Direcor | cpa ii) Head ofthe Department ee eee with blood b) Thalassemia ba ied ote by him o er related disorders | ¢) Sickle cell disease Wid) Morshidabad | if) Orthopaedic Surgeon or ix) Northag | JPMRewpert ae iv) Any other specialist depending upon the disability of the patie. Inteliectual Aisability 4) Intellectual disability ») Spe:ific learning disabilities ) Autism spectrum disorder District Hospitals, Medical Colleges Chairperson of the Board -Medical Superintendent / M.S.V.P/ Director. ii). Pediatrician or Pediatric Neurologist(where available) ili) Clinical or Rehabilitation psychologist iv) Occupational therapist ‘or Special Educator oF“Teacher trained for assessment of Specific Learning Disability( SLD). | i) Chairperson of the Board -Medical District Hospitals, | Superintendent / M.S.V.P / Medical Colleges, | Director. Institute of| ii) Psychiatrist for clinical Psychiatry, Kolkata | assessment, ined psychologist to 7 | Mental illness | a) Mental illness ‘Combination of two or more disabilities mentioned belows- 1. Blindness 2. Lon-vision 3. Leprosy cured persons 4. Hearing impairment (deaf and hard of hearing) Ree etal sat 5. Deafness Superintendent! M.S.V.P / 6. Locomotor disability Director. 7, Dwarfism ii < | 8. Intellectual disebility a eeing te dsoifaes 9, Mental illness assessing the disabilities as i per the requirement of Disabitties | Some Medical College | ii) Specific specalist(s) for 12. Muscular dystrophy assessing the respective at disabilities as per srchvotienites ant requirement ofthe disabled conditions ‘ a person, to be nominated by 14, Specific learning i siiabyinien the CMOH / Principal / 15, Multiple sclerosis reer. 16. Spech and language disability 17. Thalassemia 18, Haemophilia 19, Sickle cell disease 20, Acid Attack victims 21, Parkinson's disease For the purpose of certification, the “Guidelines for assessing the extent of specified disabilities in a person included under the Rights of Persons with Disabilities Act, 2016” issued by the Ministry of Social Justice and Empowerment, Government of India, Department of Empowerment of Persons with Disabilities’ vide Notification No. $.O. 76(E) dated 4.1.2018 isto be followed. 3. The SuperintendentiMSVP/Director of the medical institution inthe sub- division/districplace of residence of the applicant, as mentioned in the proof of residence in the application, will be the competent authority for issuing the cenificate of disability in regard to the nature of disability mentioned at serial nos. I t0 8 4, As laid down under Rule 17 of the Rights of Persons with Disabilities Rules, 2017, any person with specified disability may apply in Form IV (annexed) for a certificate of disability and submit the application to the medical authority as mentioned in Para 3 above or to the concerned medical authority in @ government hospital where she may be undergoing or may have undergonetreatments in connection with the disability. Provided that where Person ‘with disability is @ minor or cniterng Fm inelectual disability or any oter disability which renders fhim unfit or unable to make sch an application himself, the applicston on his bebalf may be made PY his Lega! guardian or by any onganization registered under the Act having the minor ‘under his care. The application shall be scuompanied by two recent passport sized photographs and proof oF residence! Aadhear No./Aaadhaar Enrollment No. 5. As laid down under Rule 18 of the Rights of Persons with Disabilities Rules, 2017, the medical authority shall, after due verification, isue a certificate of disability '9 Form V, Vi, VIL, as applcable (annexed) within a month fom date of receipt of an application fan applicant is found to te ineligible for issuance of certificate of disability, the medical euRonty shall convey the reasons to Pinca writing under Form VIIT (annexed) within a period of one month from date of receipt of application. ‘This order will take immediate effect. rer —t. ——TA]0 6 gharad e Daivea | o!'® Joint Secretary to the Government of West Bengal ‘No, 289/1(11VHF/O/PHP/IR-05/2017 29.8.2018 Copy forwarded for information and necessary action to the:- Ty bircoror of Medical Education and Ex-Oifci Secretary, West Bengal 2) Direstor of Health Services and Ex-Officio Secretary, West Bengal 3) Principal/MSVP, Medical College (all) 4) State Family Welfare Officer, H&:PW Department 5) Chief Medical Officer of Health (all) & The Director, nsue of Psychiatry, Kolkata/Bangur Insite of Newossien Kolkata 7) The Superintendent, are . Hospital (eal) 8). St. PA to Secretary, Child Development Department and Women Development & Social Welfare Deparment, Bikash Bhawan, Salt Lake, Kolkata - 700091 9) 8° PA to Commissioner of Family Welfare, H&FW Department ‘OSD (IT) to display in the official website of this. Department. sbevca.\eit 11) Guard file: Health & Family Welfare DepartmentFORM: IV Apoticaton for Obsining Conese of Disability by Persons wih Disables {See mb IMD] () Nee: (amare) (ist Name) (Midi Nar) (2) others Name ;______—_ Mother Name: _____—— (8) Date of ith 1 (Daw) (Monti (Yen) (a) Agestthetine of application ;_____years (6). Sex Mae!Fenle/Transgense (6) Address: (a) Permanent addpess _(b) Curent Ades (for communication) {© Petod since when wesing at curent address ‘Bdweational Status (please () PostGraduate i) Graduate (i) Diptoma Ais) Higher Secondary (vy High Seto! (si) Middle 0 (oi) Primary (ois) Nonsitemte (9) Oveupation (9) fdentication marks () —_—____—— (10) | Noture of isabity (U1) Pero since when sable: xs Bithsinet ett (2) Did youeverspply or ssucofa cnet oobi a thepest—__ye/00 ___—_ i A yes, details: {@) Authorty to whom and distil in which applied1h) Result of application _—— (13) Heveyou everbeentsued erin of debit in hepas? Hash wNasS enclose arte copy esiaton: (ney del that all pated stated. above a 0 of ay know edge and belie, and 20 Deca pn as been cance or mBsne, aera fay MACSIREY © detected in the applcetion, ape able vo foreture ofany bene derived another esi a Date : Phe: Fclsurst 1. Proof of esidance (Please tek a applsab ie) (a) ration cad, (0)_voteridentty ea, (6) deving eens, @ bankpassbook, (@) PAN cert, (passport, per _———__—_ (signature oF Fe thumb impression Genoa wits denbliy, or Of hither egal guardian in et8e, of Portons wth infest! disci, atbim conceal palsy nd ciple sabi, 0) {g) tephonecltty, vate anny thetity Blind address ofthe appiamt, (i) acectfeate of esidence souedby a Panchey at mainspaliy, cantonient boar any gazetted a gett ssed Pawar Head Mast of Covert xch0oL (yineaseofan inmate of sient iasthatin far prone wh sabes (0S uate of residence fom head of suc nstnution. 1. Two ween passportsize photographs Foc offee wseo Pom esttutementaly 1, and oterissbilty, nly) Signatur’ of istinganthorty stan Ccertfeate of Disability cases oarutton compte prazent pas fet ord andin cascof blindness) {see rule 1800) (ame and Address ofthe Mesial At! ost osuing the Cethieate) Recent passpon sia attested photograph (Soowing face onl) of the person with seb.(Ceteate No. De: ‘This st cory that Tae cafly camined | Siiaceitom iiaughter of Shiba of Birth (DD/MM/Y¥) Tyee. alone egiaton No _____—rrnt Ward Vilage Stet Post Office Distt ibe above and am satis that: ‘eaident ofHouse No. State ‘whose photograph ls (W hileheis acaseof + ecomptor disability + warts + blindness (Pease tisk a8 appficabs) (8) the diagnosis in hiser cases % Ga Figure) perwent (inwards) permanent locomoter camber and (A) else has tay vartsblindness Tacetion to hitvner_——(pon ofb0dy) as per viens ¢ ~ ‘dtc of su ofthe guidelines to be sped). 2, Theapplant has submited the fobowing document as profofresidene= ‘ature of Document Date oftssue Dats of suthorty suing cette (Signature and Seal of Authorised Signatory of noted Medica! Authority) ‘Signatuethamb impression of the person in whose favour ceritiate of Aisaby is issued Fon -VI Cerificate of Dsabiliy a cases oFeipl disabilities) (Seo rate 18} (ome and Adaressof theMedical Authory rung the Crifeste) Recent _passpon she tent photograph {Stowing fice only)of the bi Ccerifcae No. Dare: This to caily that weave cafilyeximined —ShiSit/Ke, soit danger of ‘Shri Date of Bith (DDIM), Age__—_yews, malelfonae resident of House, ______ Wand/ilge/tret Regatation No, pemanent Post Ofte Distt State ‘whose photograph avec ‘hove and wat that(A) heb a case of Muliple Disability, Hisyherexent of permanent physizal impairment Sisabilty has ben eva Hate! to per pldngs (nn anumber ad cate of issue of he gideees to be specified) forthe disables eked tbo ai is showa aginst the relevant dsaity in the able Be S| Debi Tiesed pa of | Diagnosis manent phystal mpanmendmeHal i" fanbiay a 9) sonata Tsay scalar Dystrophy ay cured Dra Corobel Pals ‘Reid aac Vic Low vision Biindaess Dest Tard oF Hear Speech and Language cabin, Tnelectual Deabiily este Learning DSibi ‘Autism Spectrum Disorder ental ess aie Team Conditions Mullipl soe TR | Parkinson's disease | Faemsphila 70_| Thalassemia ‘21 [ Soke Cell disease {B) nthe ght ofthe above his/her overall emmanentphyselimpuiment as per guile (0 ontmber an date “Stssuzor the guidelines tobe specied) i sfllows =~ In gues := —-—— Inwords = 2. This condition s progressiveinon-progresivelheytonprove/at key tofmprove 3, Reassessment of disebity i pereeat notnecessay, i) is recor ndedfaMer months, and therefore this ceieate shall be val ti (pd) (mM) YY) oa tangrecemte Po ane arene) «spanner tee ‘Nature ofdocuneat Date oF sue Deals oF anthony ssuingcertfene _| Signature and sealof the Medical Author. ‘Name and Seal of Member ‘Name and Seal of Member Kane and Seal of the Chapeson——— ‘Signetuethumb impression ofthe person in whose avourcetfate of isubity is issued orm Vi Centifonts of Disabilty (dn cases oterthan those mendoned ia Forms Vand Vt) (Name and Address ofthe Medical Autborky issuing te Crtifeae) {See mle 180) Recent passport fae ‘atest photograph (Growing face only) ofthe person wit Certieate No Date: This to cently that Thave carefully examined She’Se/Kum, sonlvitldaughter of Sit Date of ith (DDAMM/YY,__Age__yews, ‘alone Region No, pemanent rallent of House No. Ward/VilageTSoe= Post Off whose photograph is bed above, and am oO hesbiliy, Histher exten of percentage physia! impalrmenvdisabity has bee ‘aluated as por galcines (,.,ammber nnd date of issue ofthe guidelines to be specied) and i shown against the reevant disability in the table below. Tie, | beasTiy ‘Ried pan ot] Dlagnoss Femaneat physiead body ‘npaimmentinestel disability. (a 6 Toeommtor dab {useular Dyst rosy cured bral Pals ‘eid atack atin Dea ‘peach and Language eb Tnielestna’ OnE ‘Specific Leeming Disb Tewoiogial Conditions Parkinson's discs Ter 19] Sik Cel disease (ease strikeout the disabites which a not applicable)The above conditions progressive/non-progresivrikely to improve!nt kel to improve 3, Reassessment of disebily is: (iy aataccessaryoF (i) is evommndetiater____years rronths, and thewore tis centicate shall be vas tat (DMM) @ -2g, LeiRighifboth armsiegs 4 - eg. Single eye/bath eyes €- og. LM Rightboth ears {A Thepplicnt has submited the folowing document as proof resdence ature of document Date offsue ‘Dota ofauthoriy swing eertiente “(Authorsed Signatory of notifed Medical Authosy) (Ware and Seal) CCoustersigned {Countersignature and sea ofthe Chief Metical Oncer/Meical Superintendent! ead of Government Hospital in casethe Certificate i issued bya medical athoriy who i rota Government servant with sea} Signatuethub inpression of the penon in whose favour cerifcate of lisabilty 5 issued Note incase tis coteatefibsuedby armel authorty who snot a Government servant shale wad ony ountesignedby the Chief Medical Oieer of the Distt FORM = ith {tatinasion of rection of Applsation forCarticste of Disetiliy] [see rule 18 No, Dated Te, (Name andadress ofappiant for Cetiicate of Disability) ‘Si Madam, Peat eer to yourappivation dated___forisueofa Crise of Disbity for the folowing dsabty: PREECE Cee cee ese T Pussantto heatove aplication, you hevebeen amined by the undersigned” Medial Auoriy on 2, al mpuis eon tha forte reasons nealined below, # pot posibleo sues Cercle of Daily (ayo favour o @ «iy—_—_ 3 ease yous approved byibe econo your applzaton, you my epee requesting for review of this decision, ° ‘Yours ith, (Authorised Signatory ofthe noted Medical Author) (lame and Sea)