APPLICATION FORM FOR OBTAINING DISABILITY CERTIFICATE IDENTITY CARD/PASS BOOK FOR PERSONS WITH DISABILITY Date Part (A) Detail Particulars of the Applicant 1. Name (in block letters) 2. Father Mother Husband Guardian's name 3. Date of Birth Age 4. Sex 5 Marital Status 6. Address. a) Permanent Address b) Address for Communication 7. Educational Status 8. Family Income 9. Occupation of Applicant 10. Registration in Employment Exchange, a) Registration No Dated b) Name of Exchange 11. Identification mark 12. Blood Group Signature/Thumb impression of Applicant or legal Guardian for person with MR/Autism/ CP & Multiple Disability Part (B) Details of Assessment (For use of the Medical Board) i). Locomotor Disability (LD) 1. The case of the applicant is .............................................................................................................................. 2. Nature of Disability .......................................................................................................................................... in relation to his/her......................................................................................................................................... 3. Degree/Percentage of disability....................................................................................................................... 4. His/her condition is progressive/non-progressive/likely to improve/not likely to improve 5. Re-assessment is not recommended/is recommended after a period of ......................month/year Signature of Specialist/Doctor (Seal) Photo (2 Pass Port & 2 Stamp Size) Registration No. iii) Visual Impairment (VI) 1. The case of the applicant is .............................................................................................................. 2. Nature of Disability ................................................................................................................................ in relation to his/her............................................................................................................................ 3. Degree/Percentage of disability................................................................................................................. 4. His/ her condition is progressive/ non-progressive/ likely to improve/ not likely to improve. 5. Re-assessment is not recommended/is recommended after a period of ....................... month/ year Signature of Specialist/Doctor (Seal) iv) Mental Retardation/Mental Illness (MR/MI) 1. The case of the applicant is .............................................................................................................. 2. Nature of Disability ................................................................................................................................ in relation to his/her........................................................................................................................... 3. Degree/Percentage of disability................................................................................................................ 4. His/ her condition is progressive/ non-progressive/ likely to improve/ not likely to improve. 5. Re-assessment is not recommended/ is recommended after a period of...................... month/year Signature of Specialist/Doctor (Seal) ii) Hearing Impairment (HI) 1. The case of the applicant is ................................................................................................................ 2. Nature of Disability ............................................................................................................................................................ in relation to his/her............................................................................................................................ 3. Degree/Percentage of disability........................................................................................................... 4. His/ her condition is progressive/ non-progressive/ likely to improve/ not likely to improve. 5. Re-assesment is not recommended/is recommended after a period of ......................... month/year Signature of Specialist/Doctor (Seal) V) Multiple Disabilities 1. The case of the applicant is ............................................................................................................. 2. Nature of Disability ............................................................................................................................... in relation to his/her ......................................................................................................................... 3. Degree/ Percentage of disability.......................................................................................................... Calculation for the total percentage of MD :- a+b (90-a) 90 PSYCHOLOGICAL ASSESSMENT REPORT 1. Date of Assessment:- ....................... 2. Date of Birth.............................3. Age............................. 4. Sex ................................................... 5. Test Administered................... ............................................ 6. I.Q Score/Disability Score ................................................................................................................ 7. Level of Disability ............................................................................................................................ 8. Degree/Percentage of disability ....................................................................................................... 9. Remarks :- (Signature of the Psychologist) (Seal)
