FORM-PwD (IV)
Form-IV
Disability Certificate
(In cases other than those mentioned in Forms II and III)
(NAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE
CERTIFICATE)
(See rule 4)
Recent PP size
attested photograph
(showing face only)
of the person with
disability
Certificate No.___________________________________________ Date:
This is to certify that I have carefully examined
Shri/Smt./Kum.____________________________________________ son/ wife/daughter of
Shri___________________________________________________
Date of Birth (DD/MM/YY) ___________________________ Age_________ years,
male/female________________ Registration No. _____________________________________
permanent resident of House No. _________________________________ Ward/Village/Street
_____________________________ Post Office _________________________________
District ______________________________ State
__________________________________________, whose photograph is affixed above, and am
satisfied that he/she is a case of disability.
1. His/her extent of percentage of physical impairment/disability has been evaluated as per
guidelines (to be specified) and is shown against the relevant disability in the table below:
S. Disability Diagnosis Permanent physical impairment /
No. mental disability (in %)
1 Locomotor disability
2 Visual Impairment (blindness / low vision)
3 Hearing impairment
4 Speech and language disability
5 Intellectual disability
6 Mental-illness
7 Disability caused due to chronic
neurological conditions and / or blood disorders
(Please strike out the disabilities which are not applicable.)
2. The above condition is progressive/ non-progressive/ likely to improve/ not likely to improve.
3. Reassessment of disability is:
a. not necessary
Or
b. is recommended/after _________ years ________ months, and therefore this certificate
shall be valid till (DD/MM/YY) ___________________
4. The applicant has submitted the following document as proof of residence:
Nature of Document Date of Issue Details of authority issuing certificate
(Authorised Signatory of notified Medical Authority)
(Name and Seal)
Countersigned
{Countersignature and seal of the CMO/Medical Superintendent/Head of Government Hospital,
in case the certificate is issued by a medical authority who is not a government servant (with
seal)}
Signature/Thumb impression of the person in
whose favour disability certificate is issued.
Note: In case this certificate is issued by a medical authority who is not a government servant, it
shall be valid only if countersigned by the Chief Medical Officer of the District. Note: The
principal rules were published in the Gazette of India vide notification number S.O. 908(E), dated
the 31st December, 1996.
