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)

No.

Date :

1) 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…………………………

2) Specific recommendation :

(i) Detailed description of illness/disability alongwith investigations, if any:

(ii) Is 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.

(iv) Is the ailment/disability serious enough to 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.S-13020/1/2012-MS/MH-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/date :

(Medical Superintendent)
(Seal with Name)