Format to Issue Medical Disability Certificate for allotment of Government Accommodation
Government of India
DR. RAM MANOHAR LOHIA HOSPITAL
SAFDARJUNG HOSPITAL
ALL INDIA INSTITUTE OF MEDICAL SCEINCES
(Please Strike out whichever is not applicable)
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No.
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Date
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1)
General Observations:
General Observations:
This is to certify that Ms/Mrs/Mr.
_________________________________ aged _____ years, Male/Female, son/daughter/wife/husband/father/mother/brother/sister/mother
or father-in-law of
Ms/Mrs/Mr______________________________________________, is
a diagnosed case of ___________________________________________________________
and is undergoing treatment in the department of ______________________________________
of this Hospital since ________________________________.
_________________________________ aged _____ years, Male/Female, son/daughter/wife/husband/father/mother/brother/sister/mother
or father-in-law of
Ms/Mrs/Mr______________________________________________, is
a diagnosed case of ___________________________________________________________
and is undergoing treatment in the department of ______________________________________
of this Hospital since ________________________________.
2)
Specific recommendations:
Specific recommendations:
(i) Detailed
description of illness/disability alongwith investigations, if any:
description of illness/disability alongwith investigations, if any:
(ii) Is
the disability permanent or likely to improve with time.
the disability permanent or likely to improve with time.
(iii) Class/stage
of disease/percentage/grade of functional disability inspite of optimum
treatment and intervention,
of disease/percentage/grade of functional disability inspite of optimum
treatment and intervention,
(iv) Is the ailment/disability serious enough to
be considered for allotment or change of Govt. Accommodation at any / Ground
Floor on overriding priority:
be considered for allotment or change of Govt. Accommodation at any / Ground
Floor on overriding priority:
Signature of patient/Guardian
}
}
Alongwith Attested Photograph}
Note:- Physical disability
certificates issued by single doctor in pursuance of Guidelines No.
5-13020/1/2010-MS/MI-I-II of Directorate General of Health Services (Medical
Hospital Section-II), Nirman Bhawan, dated 18.6.2010 is also acceptable.
certificates issued by single doctor in pursuance of Guidelines No.
5-13020/1/2010-MS/MI-I-II of Directorate General of Health Services (Medical
Hospital Section-II), Nirman Bhawan, dated 18.6.2010 is also acceptable.
Signatures of Members of
Board alongwith rubber-stamp/dale:
Board alongwith rubber-stamp/dale:
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(Member)
(Seal with Name)
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(Member) (Seal with Name)
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(Member) (Seal with Name)
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(Medical Superintendent)
(Seal with Name)
COMMENTS