The annual report of the Department of Empowerment of Persons with Disabilities shall include a chapter on National Fund.
FORM–I (Persons with Disabilities Employer’s Return) [See rule 13 (1)] Six monthly return to be submitted to the Special Employment Exchange for the half year ended… ……………………………………………………………… Name and Address of the Employer…………………………………………………… Whether - Head Office…………………………………………… Branch Office…………………………………… Nature of business/principal activity:…………………………………………………
1. Employment (a ) Total number of persons including working proprietors/ partners/ commission agents/contingent paid and contractual workers, on the pay rolls of the Government establishment excluding part -time workers and apprentices. (The figures should include every person whose wage or salary is paid by the Government establishment).
37 II (i) On the last working day of the previous half year Blindne ss and low vision Deaf and hard of hearing Locomotive d isability including cerebral palsy, leprosy cured, dwarfism, acid attack victims and muscular dystrophy Autism, intellectual disability, specific learning d isability and mental illness Multiple disabilities from amongst persons with disabilities under columns
(1) to (4) including deafblindness
(1) (2) (3) (4) (5) On the last working day of the half year under report Blindne ss and low vision Deaf and hard of hearing Locomotive disability including cerebral palsy, leprosy cured, dwarfism, acid attack v ictims and muscular dystrophy Autism, intellectual disability, specific learning d isability and mental illness Multiple disabilities from amongst persons with disabilities under columns
(1) to (4) including deafblindness
(1) (2) (3) (4) (5) Men with disability Women with disability Total ------ ---- ----- ----- ---- ----- ----- ---- ----- ----- ---- --
(b) Please indicate the main reasons for any increase or decrease in employment if the increase or decrease is more than 5% during the half year.
2. Vacancies.- Vacancies carrying total emoluments as per prevailing minimum wage per month and of over six months duration.
(a ) Number of vacancies occurred and notified during the half year and the number filled during the half year (Separate figures may be given for men with disability and women with disability).
Number of vacancies which come within the purview of the Act.
Occurred Notified Filled Source (Describe the source from which filled) Local/Special Employment Exchange General Employment Exchange
(b) Reasons for not notifying all vacancies occurred during the half year under report vide 2(a) ………………………….
3. Manpower Shortages Vacancies/posts unfilled because of shortage of suitable applicants.
Name of the occupation or Designation of the posts Number of unfilled essential qualification vacancies/posts essential experience disability wise experience not necessary 1 2 3 4 Please list any other occupations for which this Government establishment had recently any difficulty in obtaining suitable applicants.
Signature of employer Dated…….
38 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] To The Employment Exchange ----------------------------- ------------------------------ Note.- This return relates to half yearly ending 31st March/30th September and shall be rendered to the local Special Employment Exchange within thirty days after the end of the half year concerned.
Form -II (Persons with Disabilities Employer’s Return) [See rule 13 (1)] Occupational return to be submitted to the local Special Employment Exchange once in two years.
Name and Address of the Employer………………………………………………………………….
Nature of business (describe what the Government establishment makes or does as its principal activity)
1. Total number of persons on the pay rolls of the Government establishment on (Specify date)…………(This figure should include every person whose wage or salary is paid by the Government establishment)(Separate figures for men with disability and women with disability may be given).
2. Occupational classification of all employees as given in item -1 above.
(please give below the number of employees in each occupation separately) Occupation Number of Employees Use exact terms Men with disability Women with disability Total Such as Engineer (Mechanical);
Please give as far as possible approximate number of vacancies in each occupation you are likely to fill during the next calendar year due to retirement.
Teacher (domestic/science);
Officer on duty (actuary);
Assistant Director (Metallurgist);
Scientific Assistant (chemist);
Research Officer (economist);
Instructor (carpenter);
Supervisor(tailor);
Fitter(internal Combustion engine);
Inspector Sanitary); Superintendent Office; apprentice Electrician).
Total Dated……………………….. Signature of employer To The Employment Exchange (please fill in here the address of your local Special Employment Exchange) Note: Total of column 5 under item 2 should correspond to the figure given against item-1.
39 II (i) FORM–III (Persons with Disabilities Employer’s Return) [See rule 14] Name and Address of the Employer…………………………………………………… Whether - Head Office…………………………………………… Branch Office…………………………………… Nature of business/principal activity: …………………………………… Total number of persons on the pay rolls of the Government establishment (This figure should include every person whose wage or salary is paid by the Government establishment).
Total number of persons with disabilities (disability-wise) on the payroll of the Government establishment(This figure should include every person with disability whose wage or salary is paid by the Government establishment).
(a ) Occupational qualification of all employees (Please give below the number of employees in each occupation separately.
Occupation Number of Employees Use exact terms Men with disabilities Women with disabilities Total Such as Engineer (Mechanical);
Please give as far as possible approximate number of vacancies in each occupation you are likely to fill during the next calendar year due to retirement.
Teacher (domestic/science);
Officer on duty (actuary);
Assistant Director (Metallurgist);
Scientific Assistant (chemist);
Research Officer (economist);
Instructor (carpenter);
Total
(b) Please indicate the main reasons for any increase or decrease in employment if the increase or decrease is more than 5% during the half year…………………………..
2. Vacancies: Vacancies carrying total emoluments as per prevailing minimum wage per month and of over six months duration.
(a ) Number of vacancies occurred and notified during the half year and the number filled during the half year.
Number of vacancies which come within the purview of the Act Occurred Notified Local Special Employment Exchange Filled Sources (Describe the source form which filled General emplo ym ent 1 2 3 4 5 Total
(b) Reasons for not notifying all vacancies occurred during the half year under report vide (a) 2 .above. ……………… 40 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
3. Manpower shortages Vacancies/posts unfilled because of shortage of suitable applicantions Name of the occupation or Designation of the posts Number of unfiled vacancies/posts ------------------------------------------------ Essential qualification Essential experience Experience Not necessary
1. 2. 3. 4.
Please list any other occupations for which this Government establishment had recently any difficulty in obtaining suitable applicants.
Dated… .
FORM- IV Signature of employer Application for Obtaining Certificate of Disability by Persons with Disabilities [See rule 17(1)]
(1) Name :
(Surname) (First Name) (Middle Name)
(2) Father's Name : Mother's Name:
(3) Date of Birth : / / (Date) (Month) (Year)
(4) Age at the time of application : years
(5) Sex: Male/Female/Transgender
(6) Address:
(a ) Permanent address (b) Current Address (i.e. for communication)
(c) Period since when residing at current address
(7) Educational Status (please tick as applicable) (i ) Post Graduate (i i ) Graduate (i ii ) Diploma
(iv) Higher Secondary
(v) High School (vi ) Middle (vi i ) Primary (vi i i ) Non-literate
(8) Occupation
(9) Identification marks (i) (1 0) Nature of disability :
(i i ) (1 1) Period since when disabled: From Birth//since year (1 2) (i) Did you ever apply for issue of a certificate of disability in the past yes/no (i i ) If yes, details:
(a ) Authority to whom and district in which applied 41 II (i)
(b) Result of application (1 3) Have you ever been issued a certificate of disability in the past? If yes, please enclose a true copy.
Declaration: I hereby declare that all part iculars stated above are true to the best of my knowledge and belief, and no material informat ion has been concealed or misstated. I further state that if any inaccuracy is detected in the application, I shall be liable to forfeiture of any benefits derived and other action as per law.
(signature or left thumb impression of person with d isability, or of his/her legal guardian in case of persons with intellectual disability, autism, cerebral palsy and mult iple disabilities, etc) Date :
Place:
Enclosures:
1. Proof of residence (Please tick as applicable).
(a ) ration card,
(b) voter identity card, (c ) driving license,
(d) bank passbook, (e ) PAN card,
(f) passport,
(g) telephone, electricity, water and any other utility bill indicating the address of the applicant,
(h) a certificate of residence issued by a Panchayat, municipality, cantonment board, any gazetted officer, or the concerned Patwari or Head Master of a Government school,
(i) in case of an inmate of a residential institution for pers ons with disabilities, destitute, mentally ill, and other disability, a certificate of residence from head of such institution.
2. Two recent passport size photographs ------------------------------------------------------------------------------------------- --- (For office use only) Date:
Place: Signature of issuing authority Stamp Form-V Certificate of Disability (In cases of amputation or complete permanent paralysis of limbs or dwarfism and in case of blindness) [See rule 18(1)] (Name and Address of the Medical Authority issuing the Certificate) Recent passport size attested photograph (Showing face only) of the person with disability.
42 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] 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. perma ne nt resident of House No. Ward/Village/Street Post Office District State , whose photograph is affixed above, and am satisfied that:
_ ( A) he/she is a case of:
• locomotor disability • dwarfism • blindness (Please tick as applicable) (B) the diagnosis in his/her case is (A) he/she has % (in figure) percent (in words) permanent locomotor disability/dwarfism/blindness in relation to his/her (part of body) as per guidelines ( number and date of issue of the guidelines to be specified).
……………
2. The applicant has submitted the following document as proof of residence:- Nature of Document Date of Issue Details of authority issuing certificate (Signature and Seal of Authorised Signatory of notified Medical Authority) Form - VI Certificate of Disability (In cases of multiple disabilities) [See rule 18(1)] (Name and Address of the Medical Authority issuing the Certificate) Certificate No. Date:
This is to certify that we 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:
Signature/thumb impression of the person in whose favour certificate o f disability is issued Recent passport size attested photograph (Showing face only) of the person with disability.
43 II (i) ( A) he/she is a case of Multiple Disability. His/her extent of permanent physical impairment/disability has been eva luated as per guidelines (……………number and date of issue of the guidelines to be specified) fo r the d isabilit ies ticked below, and is shown against the relevant disability in the table below:
Sl.
No.
Disability Affected part of body Diagnosis Permanent physical impairment/mental disability (in %)
1. Locomotor disability @
2. Muscular Dystrophy
3. Leprosy cured
4. Dwarfism
5. Cerebral Palsy
6. Acid attack Victim
7. Low vision #
8. Blindness #
9. Deaf £
10. Hard of Hearing £
11. Speech and Language disability
12. Intellectual Disability
13. Specific Learning Disability
14. Autism Spectrum Disorder
15. Mental illness
16. Chronic Neurological Conditions
17. Multiple sclerosis
18. Parkinson’s disease
19. Haemophilia
20. Thalassemia
21. Sickle Cell disease (B) In the light of the above, his/her over all permanent physical impairment as per guidelines (……….number and date of issue of the guidelines to be specified), is as follows : - In figures : - percent ------------------ In words :- percent ---------------------------------------------------------------------------
2. This condition is progressive/non-progressive/likely to improve/not likely to improve.
3. Reassessment of disability is :
(i ) not necessary, or (i i ) is recommended/after years months, and therefore this certificate shall be valid till ............... ................
----- ----- ------ (DD) (MM) (YY) @ e.g. Left/right/both arms/legs # e.g. Single eye £ e.g. Left/Right/both ears
4. The applicant has submitted the following document as proof of residence:- Nature of document Date of issue Details of authority issuing certificate
5. Signature and seal of the Medical Authority.
Name and Seal of Member Name and Seal of Member Name and Seal of the Chairperson 44 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)] Form – VII Certificate of Disability (In cases other than those mentioned in Forms V and VI) (Name and Address of the Medical Authority issuing the Certificate) [See rule 18(1)] 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. His/her extent of percentage physical impairment/disability has been evaluated as per guidelines ( number and date of issue of the guidelines to be specified) and is shown against the relevant disability in the table below:- ……..
Sl. No. Disability Affected part of body Diagnosis Permanent physical impairment/mental disability (in %)
1. Locomotor disability @
2. Muscular Dystrophy
3. Leprosy cured
4. Cerebral Palsy
5. Acid attack Victim
6. Low vision #
7. Deaf €
8. Hard of Hearing €
9. Speech and Language disability
10. Intellectual Disability
11. Specific Learning Disability
12. Autism Spectrum Disorder
13. Mental illness
14. Chronic Neurological Conditions
15. Multiple sclerosis
16. Parkinson’s disease
17. Haemophilia
18. Thalassemia
19. Sickle Cell disease (Please strike out the disabilities which are not applicable) Signature/thumb impression of the person in whose favour certificate of disability is issued.
Recent passport size attested photograph (Showing face only) of the person wit h disability 45 II (i)
2. The above condition is progressive/non-progressive/likely to improve/not likely to improve.
3. Reassessment of disability is:
(i ) not necessary, or (i i ) is recommended/after years months, and therefore this certificate shall be valid till (DD/MM/YY) @ - eg. Left/Right/both arms/legs # - eg. Single eye/both eyes € - eg. Left/Right/both ears
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 Chief Medical Officer/Medical Superintendent/ Head of Government Hospital, in case the Certificate is issued by a medical authority who is not a Government servant (with seal)} 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 FORM - VIII [Intimation of rejection of Application for Certificate of Disability] [See rule 18 (4)] No.
To, Dated :
(Name and address of applicant for Certificate of Disability) Sub: Rejection of Application for Certificate of Disability Sir/ Madam, Please refer to your application dated for issue of a Certificate of Disability for the following disability:
2. Pursuant to the above application, you have been examined by the undersigned/ Medical Authority on , and I regret to inform that, for the reasons mentioned below, it is not possible to issue a Certificate of Disability in yo ur favour:
_
(i)
(ii) (i ii ) Signature/thumb impression of the person in whose favour certificate of disability is issued 46 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
3. In case you are aggrieved by the rejection of your application, you may represent to , requesting for review of this decision.
Yours faithfully, (Authorised Signatory of the notified Medical Authority) (Name and Seal) [F. No. 03-01/2017-DD-III] DOLLY CHAKRABARTY, Jt. Secy.
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064 and Published by the Controller of Publications, Delhi-110054.
The Gazette of India MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT NOTIFICATION
CHAPTER-I PRELIMINARY
CHAPTER II RIGHTS AND ENTITLEMENTS
CHAPTER III NODAL OFFICER IN THE DISTRICT EDUCATION OFFICE
CHAPTER V VACANCIES FOR PERSONS WITH BENCHMARK DISABILITIES
CHAPTER VI ACCESSIBILITY
CHAPTER VII CERTIFICATE OF DISABILITY
CHAPTER VIII CENTRAL ADVISORY BOARD ON DISABILITY
CHAPTER IX CHIEF COMMISSIONER AND COMMISSIONER FOR PERSONS WITH DISABILITIES
CHAPTER X NATIONAL FUND FOR PERSONS WITH DISABILITIES FORM–I Form -II FORM–III FORM- IV Form-V Form - VI Form – VII FORM - VIII