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)