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This document provides information about disability certificates and identity cards issued for differently abled persons in Karnataka. [It contains details about] the application process, required documents, medical authority guidelines, facilities provided, and instructions for card holders. Key information includes types of forms issued based on the disability, details to be included on the certificate like personal information and disability diagnosis, validity period of 10 years, and facilities that must be recorded in the identity card.

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karthi
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175 views13 pages

Handi

This document provides information about disability certificates and identity cards issued for differently abled persons in Karnataka. [It contains details about] the application process, required documents, medical authority guidelines, facilities provided, and instructions for card holders. Key information includes types of forms issued based on the disability, details to be included on the certificate like personal information and disability diagnosis, validity period of 10 years, and facilities that must be recorded in the identity card.

Uploaded by

karthi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Government of Karnataka

718965
S1.No.

DISABILITY CERTIFICATE AND IDENTITY


CARD FOR DIFFERENTLY ABLED PERSONs

Odredmec), tionst
DIRECTORATE FOR THE EMPOWERMENT
OF DIFFERENTLY ABLED AND
SENIOR cITIZENS, BANGALORE
2

aos
ETerierden 207.

(PHOTO TO BE ATTESTED BY THE


MEDICAL AUTHORITY MEMBER)
3

Rorv doses etrodhand


r O edes xos,: bbe/184/8au a/2004
onsuetb, Dao: 28-06-2004

. v233/ocuecto8 o , stioe
2.
bocancto8 dothev
3. e d doprdreo ooecto8 i o o e

4.
4. emob doñ dooess odooe
5. DFOd DoT oipezinvg sro r e

SecOA/te, aea
6. epd/NHFDC oipesioa doines sdcte

suos, optesroo, pOF doeareo odneu

9.
9. DF sk/epsod atoziesso mOFTieR
odpew
4

orots3s uet)
(DISABILITY CERTIFICATE &
IDENTITY CARD FOR THE
DIFFERENTLY ABLED PERSONs
Form No. II:-In
of amputation or
case
complete permanent paralysis of Limbs
and in case of Blindness.

Form No.III & IV:- In case of multiple


Disabilities and other single 7

Disabilities.

eo

(District
(Village) (Taluk)
gtre wg go. 383 omo6 u 24
Certificate Serial No Dated:

Name
2. 8ot/ocbo/rious
aoeated axcb
Father/Mother/Husband/
Guardian Name
3. 800atho sb DOt

Permanent Residence
Address (D.No./Main/Cross)
Do
Date of Birth
5-6-1913
5. Bo
Age HaYeas
6, 2508 (vesn&adbab

. , .cdo, to.,ad)
Specify Caste/ Sub Caste
(clearly SC, ST, OBC, & Other)
7. dep rotb
Female Male
8. evdsoer
Occupation
deatb
mpeodd Dvox eonDdodab gaore z (shed 2.34
God)
6
Name and Aldress of the
Medical Authoriey Issuing Disability
Certificate .t.lM
(eonotedoh xdoa53,/ae6öte 7OF des
bab/65/8a33/2011 Opot:8-02-2011doetds
tost sted

Differently abled persons 63t ditabiliey


diagnosed, specified and
certified
ha he
Order as

No:WCD/PHP/65/20EE Dated 18-02-20111Govt per the

As per the above


persons affixed
Certified saidPhotograph,
We are/Satisfied and I am/
persons as below
S1 Disability Affected |Diagnosis Permanent
No part of
the body physical
Impairment
Mental
1. Locomotor Disability (in%|
Disability
2. Low Vision
3. Blindness #
Both
4. Hearing
Impairment
5. Mental
Retardation
6. Mental Illness
7. Multiple
Disabilities
Please strike out (x) the
Disabilities which are
not
applicable.
A. He / She is a case of
-lporeis
Disability
wwwuuudu

His/Her extent of permanent Physical Impairment/


Disability has been evaluated as per specified
Guidelines for the disabilities ticked ( )above
and shown against the relevant Disability in the
above table.

B. 1. In the light of the above, His / Her overall


permanent Physical Impairment as per the
specified guidelines is as follows

Infigures percgnt (%)


Inwords Peioent (%)
2 . The conaition is progressive/ non progressive
likely to improve / not likely to improve

Recommended suitable Aids and Appliances


1.

2
3.
11. DBoebessd s /ae3s rbtbab
Signature:Thumb Impression
of Differently abled persons
8

12. adbd8 rbabas 88a


Identification Mark

1.

13.
2.

deatd anptoodd xozd xo


(
Mrlon

Signature of Medical
Authority Members
with Disignation/Seal/
Medical Council of India/
Karnataka Registration No.

&e

EJoriee-561
2
orl
(Chairman) Name deoo
with KM
and Seal eico, 6 G
Registration No.

() KowOp3
(Concerned Specialigt7
Name and Seal with
Ned
tue a
Kegistration

0) 3 o r i e - 5 6 1 2 0 7

Name and
nysician)
Seal with KMC
Registration No.

(DFT edes zos; 5ooea/ 65/ d t 2010,


DmOE18 psO 2011d zDd (gDDE edoer, deotreg

o . 1 0oe tpetobaYa sa eved g, xo. 2, 30

pco)
As per Govt. Order No.: baea/ 65/ PHP/2010,
Dated: 18h Feb 2011 (In case of Medical Authority
atPrimary Health Centre only Single Member
Authority is constituted, hence he has to certify
1 and remaining SI. No. 2 & 3 has to be
at S1.No.
ignored)
10

&.a.d:2002 oneots Omot:2dt snrr 20026 3d


OedeDnd.

This identity card issued as per Govt. Order


No. WCD : 33: PHP :2002 Bangalore, Dated
2nd March 2002.

AS.

95spad es, epajo-56e101


District Disabled
Welfare officer

Place: Seal:
DDOB/Date:
11

Details of Facilities given

6o. O
S1.No. Date
Details of Concerned
Facilities Officers
Provided Signature
with Seal
13

rbcb8 2detwoho 10 3 F s d ndotgdbe


weseb: 6
tdedobstot
odpayie oe8odh
1. oob85 adedodha,
ROTONo)wonoe, 8d)wa

( BeaF 0235-60-800-5-01)

wTODJ*ATDrDs

rDbe5 BeJon) raDs aDodang


4.
o doDdsoddad
39 eTd
deDDQTDôren
ewonrod

Instructions

10 years. Cards should


1 This card is valid for
this period.
be renewed after
over the ldentity
2. Transferring or Handling
corrections in
Cards to others or doing any

the cards is an offence.


to Identity Card holders
3. The facilities given
the card compulsorily
should be entered in
(or without fail).

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