Full Text
1914 GI /2024 (1) रजिस्ट्री सं. डी.एल.- 33004/99 REGD. No . D. L. -33004/99
EXTRAORDINARY
PART II —Section 3 —Sub-section (ii)
PUBLISHED BY AUTHORITY
No. 1272 ] NEW DELHI, THURSDAY , MARCH 14, 2024 /PHALGUNA 24, 1945
CG-DL-E-15032024-253066
10%
25%
10%
15%
i.
10%
i.
ii.
i.
ii.
iv.
2 31 से 40 5
3 21 से 30 10
4 11 से 20 15
5 5 से 10 20
2. 1.6 - 3.0 से.मी. 8
3. 3.1 - 5.0 से.मी. 16
1. 15⁰ तक 4
41-50° 10%
51-60° 20%
61-70° 30%
71-80° 40%
81-90° 50%
91-100° 60%
%
0 0
0.5 3
1 7
1.5 10
2 14
2.5 17
3 20
3.5 24
4 27
4.5 31
5 35
5.5 37
6 40
%
5%
10%
5%
5%
10%
10%
10%
10%
20%
2 से 3 21 से 40%
4 से 5 41 से 60%
6 से 7 61 से 70%
8 से 9 71 से 80%
10 से 11 81 से 90%
12 91 से 100%
6/24 से 6/60 10% 0
6/18 6/24 6/36 6/60 3/60 2/60 1/6
6/18 0% 10% 10% 10% 20% 30% 30% 30%
6/24 10% 40% 40% 40% 50% 60% 60% 60%
6/36 10% 40% 40% 40% 50% 60% 60% 60%
6/60 10% 40% 40% 40% 50% 60% 60% 60%
3/60 20% 50% 50% 50% 70% 80% 80% 80%
2/60 30% 60% 60% 60% 80% 90% 90% 90%
1/60 30% 60% 60% 60% 80% 90% 90% 90%
पीएल - 30% 60% 60% 60% 80% 90% 90% 100%
<40°से 20° <20°से 10°
<10°
<40°से20° 40% 50% 60%
<20°से10° 50% 70% 80%
<10° 60% 80% 100%
0 to 25 0 61 41.71
26 1 62 43.42
27 1 63 45.13
28 1 64 46.84
29 1 65 48.55
30 1 66 50.26
31 1 67 51.97
32 1 68 53.68
33 1 69 55.39
34 2 70 57.1
35 3 71 58.81
36 4 72 60.52
37 5 73 62.23
38 6 74 63.94
39 7 75 65.65
40 8 76 67.36
41 9 77 69.07
42 10 78 70.78
43 11 79 72.49
44 12 80 74.2
45 13 81 75.91
46 14 82 77.62
47 15 83 79.33
48 16 84 81.04
49 17 85 82.75
50 18 86 84.46
51 19 87 86.17
52 20 88 87.88
53 21 89 89.59
54 22 90 91.3
55 23 91 93.01
56 24 92 94.72
57 25 93 96.43
58 26 94 98.14
59 27 95 100
60 40
1 0-15
2 16-30
3 31-39
4 40-55
5 56-75
6 76-89
7 90-100
0 100 98.9 97.8 96.8 95.7 94.6 93.6 92.5 91.4 90.4
1 89.3 88.2 87.2 86.1 85.0 84.0 82.9 81.8 80.8 79.7
2 78.6 77.6 76.5 75.4 74.4 73.3 72.2 71.2 70.1 69.0
3 68.0 66.9 65.8 64.8 63.7 62.6 61.6 60.5 59.4 58.4
4 57.3 56.2 55.2 54.1 53.0 52.0 50.9 49.8 48.8 47.7
5 46.6 45.6 44.5 43.4 42.4 41.3 40.0 39.2 38.1 37.1
6 36.0 34.9 33.9 32.8 31.7 30.7 29.6 28.5 27.5 26.4
7 25.3 24.3 23.2 22.1 21.1 20 18.9 17.9 16.8 15.7
8 14.7 13.6 12.5 11.5 10.4 09.3 8.3 07.2 06.1 05.1
9 4.0 2.9 1.9 0.8 00.0 00.0 00.0 00.0 00.0 00.0
___________________________________________________
कक्षा: _____________
___________________________________________________
"E"; " ch" के जलए "sh”;
"musim"
“mar”
29-40 मंि 40-59%
x =𝒂+𝒃(𝟏𝟎𝟎 −𝒂)
2. 20 5-50% (कारक
3. 40 <5% (कारक
4. 45 <5% (कारक
VIII या IX)
13. 90
= 0
(%)
0 3 5 8
2 2
2 2 2 3
5 0 5 0 5 0
1 0 3 0 5 0 8 0
सी (10 -15
3 0 5 0 8 0
0 3 5 8
(131-
150)
0 0 2 0 3 0 5 0 8
HbSC
40 %
40%
150)
0 2 3 5 8
5 5
2 2 2 2 2 3
5 5 5
0 1 3 5 8
ए (5 -
0 3 5 8
90-
0 3 5 8
िस्ट्तािेज़): __________________ __________________ __________________
______________________________________________________________
_____ ___________________
तारीख : _________________
______________________________________________________________________________
तारीख ______________________ :
स्ट् र्ान ______________________ :
=58%
=79%
नाम...............................……………………………………………
आयु ……………....................… डलंग ……….........
जिभाग.....................................................................……………………………………………………………
ओपीडी पंिी .सं ...................................................
जनिान .................................................. ........ ........... ..................................................
पता...................... .................................................. .................................................
.…………………………………………………………………
%
%
30%
30%
छूना 0% 3% 5% 7% 9%
करना) 0% 3% 5% 7% 9%
करना 0% 3% 5% 7% 9%
नाम……………………………………………
जिभाग..……………………………………………………………
ओपीडी रजि .सं . ..................................................
जनिान .................................................. ....... ........... ..................................................
पता...................... .................................................. .................................................
.…………………………………………………………………
%
है 0 2 4 7 9
नाम ..............................................................
egde1wonK:1roFcaF
Dimension1:Vocabulary
Item
No Item Response Score
1 SkippingRope 012
2 Calendar 012
3 Lock 012
4 TrafficLights 012
5 Cupboard 012
6 Stapler 012
7 Axe 012
8 WeighingMachine 012
9 Nail 012
10 Cat 012
11 Table 012
12 Friend 012
13 Ocean 012
14 Magazine 012
15 Dictionary 012
16 Forest 012
17 Heavy 012
18 Relax 012
19 Disappoint 012
20 Companion 012
21 Mimic 012
Total
Factor1:Knowledge
Dimension2:Information
Item
No Response Score
1 Sunlight,Water,
AirandSoil
2 Summer,Winter,
Rainy,Autumn
Earth
4 Beetroot,Carrot,Radis
h,Potato,Turnip
February
Blood
Liters
JawaharlalNehru
9 Whenwaterisheatedtoitsbo
ilingpoint,Evaporation.
Chlorophyll
11 Because
ofPressurizedSteam
Total
metI
Factor1:Knowledge
Dimension3:Comprehension
Item
No Response Score
Total
Factor2:FluidReasoning
Dimension1:VerbalAnalogies
Item
No
Item/correctresponse
Score
(Monkey:Climb::Fish :?)
Swim
(Monday:Week::January:?)
Month
(Tree:Leaf::Bird:?)
Feathers/Wings
(Page:Book::Leaf:?)
Tree/Plant
(Driver:Bus::Pilot: ?)
Aeroplane
(Foetus:Child::Seed:?)
Plant/Tree
(Pyramid:Triangle::Cube:?)
Square
8 (Phone: Communication
::Aeroplane:
?)Transportation
Total
itpsnopteR
oitabreRIe
Factor2:FluidReasoning
Dimension2:ObjectSeries
Item
No Item/Correctresponse Score
1 C 0 1
2 C 0 1
3 B 0 1
4 A 0 1
5 B 0 1
6 C 0 1
7 C 0 1
8 A 0 1
9 B 0 1
10 C 0 1
11 D 0 1
12 D 0 1
13 C 0 1
14 B 0 1
15 B 0 1
16 D 0 1
17 B 0 1
Total
Factor3:QuantitativeReasoning
Dimension1:Arithmetic
Item
No Item/C1wwFde wFsp1:sF Score
1 6 01
2 8 01
3 10 01
4 3Pencils 01
5 5 Chocolates 01
6 4 Coins 01
7 2Pencils 01
8 15Books 01
9 6Ballseach 01
10 8Kgs 01
11 9Minutes 01
12 3Apples=Rs.60 01
13 37.5 01
Total
Factor4:Visual Spgeigo RFgs1:i:a
Dimension 2 :Spgeigo C1:dFpes
Item
No Item/
correctres
ponse Response(inVerbatim) Score
1 1. Left side
2. Right-side
3. Middle
LeftHand
Farthestleftside
Leftside
Road/Tree/Wall
Leftside
Rightside
East
Total
Factor4:VisualSpatialReasoning
Dimension2:SquareConstructio nTest
Item
No CorrectR
Time
Taken(inSec
onds) Scores
Above
60Sec
45 Sec
Above12
0Sec
90 Sec
Above12
0Sec
Above12
0Sec
91-120Sec
90 Sec
Above15
0Sec 1
120Sec
Above17
0Sec 1
141-170
Sec
140Sec
Above17
0Sec 1
141-170
Sec
140Sec
Total
tpsnoptp
46-60ctS
91-120ctS
91-120ctS 2
90 ctS
121-
150c
tS
Factor5:WorkingMemory ■
Dimension1:DigitSpanForw ard
Item
No Item/Correctresponse Score
1 3-8-64-2-6 01
2 2-4-1-6 6 -2-4-7 01
3 4-6-3-5-86-4-1-7-2 01
4 1-3-5-7-9-4 6 -2-5-3-1-8 01
5 7-4-6-2-5-8-32-8-3-6-4-9-1 01
6 5-2-6-4-1-3-9-73-5-4-1-6-8-2-9 01
7 4-1-5-8-3-7-2-6-9 8 -3-6-9-5-2-7-1-4 01
Total
Dimension2:DigitSpanBackward
Item
No Item/Correctresponse Score
1 1-2 3-1 01
2 9-5-2 8-6-3 01
3 3-9-4-8 7-3-4-2 01
4 2-5-8-7-9 1-3-6-9-7 01
5 4-9-1-7-6-3 5-2-4-1-3-6 01
6 8-4-5-9-7-1-3 9-4-1-6-8-2-5 01
Total
yrSenagninaoRo5rtInaF
egde1wonK:1roFcaF
Dimension2:Information
Item
No Response Score
1 Sunlight,Water,
AirandSoil
2 Summer,Winter,
Rainy,Autumn
Earth
4 Beetroot,Carrot,Radis
h,Potato,Turnip
February
Blood
Liters
JawaharlalNehru
9 Whenwaterisheatedtoitsbo
ilingpoint,Evaporation.
Chlorophyll
11 Because
ofPressurizedSteam
Total
metI
Factor1:Knowledge
Dimension3:Comprehension
Item
No Response Score
Total
egde1w2n eouic RFgs1:i:a 2
Dimension1:VerbalAnalogies
Item
No
Item/correctresponse
Score
(Monkey:Climb::Fish :?)
Swim
(Monday:Week::January:?)
Month
(Tree:Leaf::Bird:?)
Feathers/Wings
(Page:Book::Leaf:?)
Tree/Plant
(Driver:Bus::Pilot: ?)
Aeroplane
(Foetus:Child::Seed:?)
Plant/Tree
(Pyramid:Triangle::Cube:?)
Square
8 (Phone: Communication
::Aeroplane:
?)Transportation
Total
itpsnopteR
oitabreRIe
Factor2:FluidReasoning
Dimension2:ObjectSeries
Item
No Item/Correctresponse Score
1 C 0 1
2 C 0 1
3 B 0 1
4 A 0 1
5 B 0 1
6 C 0 1
7 C 0 1
8 A 0 1
9 B 0 1
10 C 0 1
11 D 0 1
12 D 0 1
13 C 0 1
14 B 0 1
15 B 0 1
16 D 0 1
17 B 0 1
Total
Factor3:QuantitativeReasoning
Dimension1:Arithmetic
Item
No Item/Correctresponse Score
1 6 01
2 8 01
3 10 01
4 3Pencils 01
5 5 Chocolates 01
6 4 Coins 01
7 2Pencils 01
8 15Books 01
9 6Ballseach 01
10 8Kgs 01
11 9Minutes 01
12 3Apples=Rs.60 01
13 37.5 01
Total
Factor4:VisualSpatialReasoning
Dimension1:SpatialConcepts
Item
No Item/
correctres
ponse Response(inVerbatim) Score
1 1. Leftside
2. Rightside
3. Middle
LeftHand
Farthestleftside
Leftside
Road/Tree/Wall
Leftside
Rightside
East
Total
Factor4:VisualSpatialReasoning
Dimension2:SquareConstructio nTest
Item
No CorrectR
Time
Taken(inSec
onds) Scores
Above
60Sec
45 Sec
Above12
0Sec
90 Sec
Above12
0Sec
Above12
0Sec
91-120Sec
90 Sec
Above15
0Sec 1
120Sec
Above17
0Sec 1
141-170
Sec
140Sec
Above17
0Sec 1
141-170
Sec
140Sec
Total
tpsnoptp
46-60ctS
91-120ctS
91-120ctS 2
90 ctS
121-
150c
tS
Factor5:WorkingMemory ■
Dimension1:DigitSpanForw ard
Item
No Item/Correctresponse Score
1 3-8-64-2-6 01
2 2-4-1-6 6 -2-4-7 01
3 4-6-3-5-86-4-1-7-2 01
4 1-3-5-7-9-4 6 -2-5-3-1-8 01
5 7-4-6-2-5-8-32-8-3-6-4-9-1 01
6 5-2-6-4-1-3-9-73-5-4-1-6-8-2-9 01
7 4-1-5-8-3-7-2-6-9 8 -3-6-9-5-2-7-1-4 01
Total
Dimension2:DigitSpanBackward
Item
No Item/Correctresponse Score
1 1-2 3-1 01
2 9-5-2 8-6-3 01
3 3-9-4-8 7-3-4-2 01
4 2-5-8-7-9 1-3-6-9-7 01
5 4-9-1-7-6-3 5-2-4-1-3-6 01
6 8-4-5-9-7-1-3 9-4-1-6-8-2-5 01
Total
yrSenagninaoRo5rtInaF
Factor5:WorkingMemory
Dimension3:NumberNameSequence
Item
Item/Correctresponse Response(i
Trial1 Trial2
1 2clocks
6bananas 1 doll
3pens
2 3cows
8grasshoppers
5bottles 2slates
6frocks
4bags
Total
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ई-मेलnciw:innlnc2r2s:or:Feri: िेबराइटn www.nimhindia.org
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(49 nd02foe-2023
स्र्त एिां रौजन्य: http://www.bpaindia. org/EN April-JuneO6.htm
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2 Raretara na IRfaRot
RonnantItoe,Reunce RIsrRaItoe nd
braroSt Raretara RonnantItoe
,ReunceRIsrRaItoe nd braroSt
2.5 - rRaf bRaretara fRptrpt ,ReuatSnntaF no
scaa etpe
3 Raretara fRptrptn IRaf en Inftaret
fRprb
RaReF ,Reu RIsrRatf snpecaraatdat tp;
suFpRSraaF Roftstoftoe rRaf en Inftaret bRaretarafRptrp t; pnIt
snpecaraRoperbRaReF; suFpRSraaF
moftstoftoe
4 ctntataF fRprbaRo5 fRptrpt; peRaa rbat
en ,rao na perof corppRpetf ctntat fRprbRaReF; peRaa rbat en,rao na
perof corppRpetf
5 SnodRotItoe en btf na
,uttaSurRacoatpp rRftf iuttaSurRa bncof na btfaRfftocoatpp
rRftf
ALS Functional Rating Scale Revised (ALS -FRS -R)
dretn………………………………….orIt sreRtoen………………………………………………dret nd
Raeun…………………………………… ireRtoe’p
number……………………………………………………………………………………..Right -/left-handed
metI fn ciffSl
4 onaIra psttSu sanStpp
3 dtetSerbat psttSu fRpecabroSt
2 moetaaR5Rbat ,Reu atstreRo5
1 csttSu SnIbRotf ,Reu ono- nnSra SnIIcoRSreRno
0 Anpp nd cptdca psttSu
metI 0n cSAmiSmmdo
4 onaIra
3 caR5ue bce ftdRoRet t Stpp nd praRnr Ro Inceu; IrF urnt oR5ueeRIt fannaRo5
2 rnftaretaF t StppRnt praRnr; IrF urnt IRoRIra fannaRo5 efcaRo5 eut frFe
1 rraotf t Stpp nd praRnr ,Reu pnIt fannaRo5
0 rraotf fannaRo5; atrcRatp Snoperoe eRppct na urofotaSuRtd
metI nn ciSAAdimoI
4 onaIra treRo5 urbRep
3 fraaF treRo5 sanbatIp – nSSrpRnora SunoRo5
2 dRteraF SnopRpetoSF Suro5tp
1 ottfp pcssatItoe ecbt dttfRo5
0 oid et SacpRntaF sratoetara na toetara dttfRo5e
metI tn lSodiimmmoI
4 onaIra
3 can, na panssFn raa ,nafp rat at5Rbat
2 one raa ,nafp rat at5Rbat
1 Sbat en 5aRs sto, bce corb at en ,aRet
0 dorbat en 5aRs sto
metI grn SdmmmoI yddd Sod lSodAmoI dmfocmAc
ireRtoep ,Reunce 5rpeanpenIF → dpt gb Rd bg2l Rp euanc5u 5- ecbt
4 onaIra
3 cnIt,ure pan, rof SacIpF, bce on utas ottftf
2 Sro Sce Inpe dnnfp ebg2l(, raeunc5u pan, rof SacIpF; pnIt utas ottftf
1 ynnf Icpe bt Sce bF pnItnot, bce Sro peRaa dttf pan,aF
0 ottfp en bt dtf
metI gbn SdmmmoI yddd Sod lSodAmoI dmfocmAc
ireRtoep ,Reu 5rpeanpenIF → 5 b nseRno Rp cptf Rd eut sreRtoe urp r 5rpeanpenIF rof noaF Rd Re Rp eut
saRIraF Iteunf eInat euro g2l( nd treRo5 .
4 onaIra
3 SacIpF, bce rbat en stadnaI raa IroRscareRnop RoftstoftoeaF
2 cnIt utas ottftf ,Reu Sanpcatp rof drpetotap
1 iannRftp IRoRIra rppRperoSt en Srat5Rnta
0 dorbat en stadnaI roF rpstSe nd erpo
SAc ycoSeRnora ireRo5 cSrat itnRpt f eSAc-yic- i(. itapRnon rrF 02fg
metI on difccmoI Sod l Imfof
4 onaIra dcoSeRno
3 moftstoftoe rof SnIsatet ptad- Srat ,Reu tddnae na ftSatrptf tddRSRtoSF
2 moetaIReetoe rppRperoSt na pcbpeRecet Iteunfp
1 ottfp reetofroe dna ptad- Srat
0 mnera ftstoftoSt
metI 7 n mdiomoI mo fd Sod Sd dcmmoI fd SAdmlfc
4 onaIra dcoSeRno
3 cnIt,ure pan, rof SacIpF, bce on utas ottftf
2 Sro ecao ranot, na rf cpe puttep, bce ,Reu 5atre fRddRScaeF
1 Sro RoReRret, bce one ecao na rf cpe puttep ranot
0 ltasatpp
metI An iSAmmoI
4 onaIra
3 fraaF rIbcareRno fRddRScaeRtp
2 iraop ,Reu rppRperoSt
1 ono- rIbcarenaF dcoSeRnora InntItoe
0 on scasnptdca at5 InntItoe
metI Sn SAmr moI cmSmic
4 onaIra
3 can,
2 rRaf copetrfRotpp na dreR5ct
1 ottfp rppRperoSt
0 Sroone fn
metI f2n d ciofS
4 onot
3 dSScap ,uto ,raoRo5
2 dSScap ,Reu not na Inat nd eut dnaan,Ro5n treRo5, breuRo5, fatppRo5 eSdAe
1 dSScap re atpen fRddRScaeF batreuRo5 ,uto tReuta pReeRo5 na aFRo5
0 cR5oRdRSroe fRddRScaeFn SnopRftaRo5 cpRo5 ItSuroRSra atpsRarenaF pcssnae
metI ffn dimldiofS
4 onot
3 cnIt fRddRScaeF pattsRo5 re oR5ue fct en punaeotpp nd batreu, fntp one anceRotaF cpt
Inat euroe,n sRaan,p
2 ottfp t ear sRaan,p Ro nafta en patts eInat euro e,ne
1 Sro noaF patts pReeRo5 cs
0 dorbat en patts ,Reunce ItSuroRSra rppRperoSt
metI 12 n ifcimiSmdi mocdyymSmfoS
4 onot
3 moetaIReetoe cpt nd RiSi
2 SnoeRocncp cpt nd RiSi fcaRo5 eut oR5ue
1 SnoeRocncp cpt nd RiSi fcaRo5 frF u oR5ue
0 monrpRnt ItSuroRSra ntoeRareRno bF RoecbreRno na earSutnpenIF
moetanRt,ta’p
orIt………………………………………………………………………………………………………………
…
SAc ycoSeRnora ireRo5 cSrat itnRptf eSAc-yic- i(. itapRnon rrF 02fg
mut ot, nao ltrae SppnSRreRno eo lS( ycoSeRnora SarppRdRSreRno Rp r pFpetI cptf en
SarppRdF t etoe nd fRptrpt dna sreRtoep ,Reu utrae fRptrpt.
ln, en SnIsatet eut o lS ycoSeRnora SarppRdRSreRno
1 . ocaptp rof suFpRSRrop IrF SnIsatet eut o lS ycoSeRnora SarppRdRSreRno.
2 . itnRt, o lS ycoSeRnora SarppRdRSreRno dnaI.
3 . itnRt, ItfRSra atSnaf en rpptpp satptoSt rof t etoe nd SrafRrS fRptrpt, pR5op rof
pFIsenIp.
4 . dcaRo5 rpptppItoe, nbptant eut sreRtoe’p pcbeat ftstoftoSRtp rof RoetarSeRnop ,ReuRo eut
t RpeRo5 pcssnae ote,naop.
5 . moetanRt, sreRtoe rofnna drIRaF en nberRo RodnaIreRno at5rafRo5 pFIsenI nSScaatoSt,
dcoSeRnoraReF rof SnIdnae atnta cpRo5 rctpeRnop btan,.
ectpeRnop eure IrF bt cptdca Ro rpptppRo5 sreRtoep RoSacft
1 . Sat eutat roF aRIRereRnop nd suFpRSra rSeRnReF ln, IcSu iure rSeRnReRtp rat aRIRetf
2 . mp eutat roF fRpSnIdnae re atpe
3 . dntp suFpRSra rSeRnReF Sr cpt roF pFIsenIp pcSu rp dreR5ct, srasRereRno, fFpsotr, na ro5Rora
srRo
4 . ln, IcSu rSeRnReF Rp atrcRatf en Srcpt pFIsenIp onaIra rSeRnReF dna r5t, atpp euro
nafRoraF rSeRnReF, IRoRIra rSeRnReF, on rSeRnReF re raa
o lS SarppRdRSreRno - mut cer5tp nd ltr ae yrRacatn
Sarpp m - on pFIsenIp rof on aRIRereRno Ro nafRoraF suFpRSra rSeRnReF, t.5. punaeotpp nd batreu
,uto ,raoRo5, SaRIbRo5 perRap teS.
Sarpp mm - rRaf pFIsenIp eIRaf punaeotpp nd batreu rofnna ro5Ror( rof paR5ue aRIRereRno fcaRo5
nafRoraF rSeRnReF.
Sarpp mmm - rraotf aRIRereRno Ro rSeRnReF fct en pFIsenIp, tnto fcaRo5 atpp- euro- nafRoraF
rSeRnReF, t.5. ,raoRo5 punae fRperoStp e02f22 I(. SnIdnaerbat noaF re atpe.
Sarpp mi - ctntat aRIRereRnop. f staRtoStp pFIsenIp tnto ,uRat re atpe. rnpeaF btfbncof
s reRtoep.
Smi SraScareRno
● foStsuransreuFn onot p f snRoe, Iarft f rof 0 p 0 snRoep, Iarft n rof t p n snRoep
● SpSRetpn onot p f snRoe, paR5ue p 0 snRoep, Inftaret p n snRoep
● RaRacbRon cofta 0 I5nIa p f snRoe, 0 en n I5nIa p 0 snRoep , nnta n I5nIa p n snRoep
● SabcIRon 5atreta euro n.gI5nIa p f snRoe, 0.A en n.gI5nIa p 0 snRoep, atpp euro
2.8 I5nIa p n snRoep
● ianeuanIbRo mRIt eptS sanano5tf(n atpp euro t ptS p f snRoe, t en o ptS p 0 snRoep,
nnta o ptS p n snRoep
yatrctoeaF moi ,Raa bt cptf rp r pcbpeRecet dna im, ,Reu moi cofta f.o p f snRoe, moi f.o en
2.2 p2 snRoep, moi rbnnt 0.0 p n snRoep
mut ptntaReF nd SRaaunpRpn
● SuRaf- ic5u Sn g en o snRoep
● SuRaf- ic5u n o en S snRoep
● SuRaf- ic5u Sn f2 en fg snRoep
fIyi SraScarena
IanItacara dRaeareRno aret eIyi( Rp eut btpe nntaraa Roft nd oRfotF dcoSeRno. onaIra IyinraRtp
rSSnafRo5 en r5t, pt , rof bnfF pRat, rof ftSaRotp ,Reu r5t. mut oreRnora mRfotFyncofreRno
atSnIItofp cpRo5 eut Smd- fim SatreRoRot frcreRno e020f( en tpeRIret Iyi.
ueespnnn,,,.oRfotF.na5nsandtppRnorapnofnrRn5da_SraScarena
mut dnaIcar atrcRatf perofrafRatf rpprFp dna SatreRoRot. SFpereRo nract Rp Inat pstSRdRS
bcet5da SraScareRno ,Raa bt brptf no SatreRoRot Ro satptoe 5cRftaRotp.
yna stapno atpp euro fA Ftrap , r stfRreaRS 5da SraScarena Rp en bt cptf
enaitf ueespnnn,,,.oRfotF.na5nsandtppRnorapnofnrRn5da_SraScar
● md nractp dna SFpereRo S rofnna do rat one toetatf, eut SraScarena ,Raa 5totaret Iyi
tpeRIretp cpRo5 eut SatreRoRot-b rptf r tfpRft cSu,raeaq trcreRno noaF eScaatoeaF
SnopRftatf eut btpe Iteunf dna tpeRIreRo5 Iyi Ro SuRafato.e
Pain Disability ectpeRnoorRat (PDQ)
mut irRo dRprbRaReF ectpeRnoorRat eide( Rp r spFSunIteaRS tnracreRno Itrpcat nd
dcoSeRnoraperecp Ro sreRtoep ,Reu SuanoRS srRo. me Sn- ataretp ,Reu suFpRSra rof spFSunan5RSra
ucIrodcoSeRno esrRo RoetopReF, ftsatppRno e rof ,nao fRprbRaReF.
mut srRo dRprbRaReF ectpeRnoorRat Rp r Itrpcat nd dcoSeRnora perecp rof dnScptp no
fRprbRaReF,dcoSeRno, rof spFSunpnSRra nraRrbatp. muRp enna urp t Staatoe spFSunIteaRS
sanstaeRtp rofSnopRpetoeaF ftInopearetp peano5 SnaatareRnop en nra Rncp suFpRSra rof
spFSunpnSRra Itrpcatp.
irRo dRprbRaReF ectpeRnoorRat eide( Rp ftetaIRotf bF Roftstoftoe areRo5p, no r f2- snRoe pSrat
( danI 2 psnna atatnroSt en f2 p t Staatoe atatnroSt( eerbat m.e
muto eut enera snRoep SraScaretf Ro mrbat m rat Snontaetf en fRprbRaReF staStoer5tp rp pun,o Ro
mrbat mm. neu erbatp rat sannRftf.
mrbat mn irRo dRprbRaReF ectpeRnoorRat eidee
ide rctpeRnop cSnat nseRnop ftstofRo5 no aRIRereRno nd
rSeRnReRtp.
ireRtoe
ide
rSecra
snRoep
1 1 . dn tp Fnca
srRoRoetadtat ,Reu
FncaonaIra ,nao
RopRft rofncepRft
unIt 0
( ,nao onaIraaFe
1-9 10
( dorbat en ,nao
re raae
2 dntp Fnca srRo
Roetadtat ,Reu stapnora
Srat epcSu rp
,rpuRo5,
fatppRo5e 0 ( mrot Srat nd
rFptadSnIsatetaFe
1-9 10 ( ottf utas ,Reu
raa IF
stapnoraSrate
3 dntp Fnca srRo
Roetadtat ,Reu Fnca
earntaRo5 0
( earnta roF,utat m
aRote 1-9 10
( noaF earnta en ptt
fnSenape
4 dntp Fnca srRo rddtSe
Fnca rbRaReF en pRe na
perof 0
( on sanbatIpe 1-9 10
( Sroone pRenperof
re raae
5 dn tp Fnca srRo rddtSe
Fnca rbRaReF en aRde
nntautrf, 5arps
nb tSep, na atrSu dna
euRo5p
( on sanbatIpe
1-9 10
( Sroone fn re raae
6 6 . dntp Fnca srRo
rddtSe
Fnca rbRaReF en aRde 0
( on sanbatIpe 1-9
( Sroone fn re raae
nb tSep ndd eut danna,
btof, penns na prcre
7 dn tp Fnca srRo rddtSe
Fnca rbRaReF en ,rao na
aco 0
( on sanbatIpe
( Sroone fn re raae
8 lrp Fnca RoSnIt
ftSaRotf pRoSt Fnca
srRo bt5ro
( on ftSaRote
1-9 10
( Anpe raa RoSnIte
9 dn Fnc urnt en erot
srRo ItfRSreRno
tntaFfrF en Snoeana
Fnca srRo
(on ItfRSreRno
ottftfe
1-9 10
( do srRo
ItfRSreRno
euanc5unce eut
frFe
10 dntp Fnca srRo dnaSt
Fnc en ptt fnSenap
IcSu Inat euro
btdnatFnca srRo
bt5ro
( otnta ptt
fnSenape
( ctt fnSenap
,ttoaFe
11 dntp Fnca srRo
Roetadtat ,Reu Fnca
rbRaReF en ptt eut
stnsat,un rat
RIsnaeroe enFnc rp
IcSu rp Fnc,ncaf
aRot 0
( on sanbatIe
1-9 10
( otnta ptt eutIe
12 dntp Fnca srRo
Roetadtat ,Reu
atSatreRnora rSeRnReRtp 0
( on RoetadtatoSte
1-9 10
( enera RoetadtatoSte
na unbbRtp eure rat
RIsnaeroe en Fnc
13 dn Fnc ottf eut utas
ndFnca drIRaF rof
daRtofpen SnIsatet
tntaFfrF
erpop e RoSacfRo5 unIt
rof ,nao( btSrcpt nd
Fnca srRo 0
( otnta ottf utase
1-9 10
( ottf utas raa eut
eRIte
14 dn Fnc on, dtta Inat
ftsatpptf, etopt, na
ro Rncp euro btdnat
Fnca srRo bt5ro 0 (on
dtsatppRnonetopRnoe
1-9 10 ( ctntat
ftsatppRnonro RteF
15 Sat eutat tIneRnora
sanbatIp Srcptf bF
Fnca srRo eure Roetadtat
,Reu Fnca drIRaF,
pnSRra, rof na ,nao
rSeRnReRtp 0
( on sanbatIpe
1-9
( ptntat sanbatIpe
mnera ide pSnat
md sreRtoe 5tep g na Inat snRoep Ro roF fnIrRo, eutF ,Raa ottf fnScItoereRno ,Reu
pcssnaeRo5fnScItoep atSnafp. ccssnaeRo5 fnScItoereRno- dnSena’p satpSaRseRno dna srRo
ItfRSRot na unpsRera rfIRppRno atSnafp, na n- pSunna na ,nao rbptoettRpI atSnafp teS .
mIr5Ro5 Rd rnrRarbat.
inRoep enera nd ide
on srRo p 2-10
rRaf srRo p ff-70
rnftaret srRo p of-100
ctntat srRo p f2f-130
f eatIt srRo p fnf-15
mut SnontapRno nd irRo fRprbRaReF rctpeRnoorRat pSnat en fRprbRaReF 5arfRo5 Rp 5Rnto Ro mrbat mm
btan,.
mrbat mm
SnontapRno nd irRo fRprbRaReF rctpeRnoorRat snRoep en eut fRprbRaReF pSnat
ctt eut enera snRoep raaRntf danI eut
rctpeRnoorRat.
ctt eut ataretf fRprbRaReF pSnat dna
eut sreRtoe ide snRoe aro5t.
doaF not srRo fRprbRaReF pSnat Rp
5Rnto erbat en trSu sreR toe, rp sta
eut btan, SnontapRno erbat.
ireRtoe ide
inRoep
danIerbat f
dRprbRaReF pSnat
rppR5oItoe en bt
rfftf dna sreRtoep
on na IRoRIra srRo pSnat p 2 en f2
rRaf srRo p ff-70 2
rnftaret srRo p of-100 3
ctntat srRo p f2f-130 5
f eatIt srRo pfnf-150 8
-
MINISTRY OF SOCIAL JUSTICE AND EMPOWERMENT
[Department of Empowerment of Persons with Disabilities (Divyangjan)]
NOTIFICATION
New Delhi, the 12th March , 2024
S.O. 1338(E).—In exercise of the power conferred by Section 56 of the Rights of Persons with Dis abilities
Act, 2016 (49 of 2016) and in supersession of notification issued vide No. 16 -21/2013 -DD-III dated 25th April, 2016
and No. 16 -9/2014 -DD-III [S.O. 76 (E) Dated 4thJanuary, 2018] of the Ministry of Social Justice and Empowerment,
Department of Emp owerment of Persons with Disabilities (Divyangjan), the Central Government hereby notifies the
guidelines for the purpose of assessing the extent of following specified disabilities in a person after having
considered the recommendations of the sub -committ ees of experts to assess the extent of specified disabilities in a
person, detailed in the ANNEXURE, namely: -
i. Locomotor disability ;
ii. Visual Impairment ;
iii. Hearing Impairment and Speech & Language Disability ;
iv. Specific Learning Disability, Intellectual Disa bility and Autism Spectrum Disorder ;
v. Mental illness ;
vi. Blood Disorder ;
vii. Multiple Disorder ; and
viii. Chronic Neurological Disorder.
Note 1: - In terms of Section 57 of the Rights of the Persons with Disabilities Act, 2016 (49 of 2016), the State
Government or U nion Territory Administrators or as the case may be shall designate persons, having requisite
qualifications and experience, as certifying authorities, who shall be competent to issue the certificate of disability and
also notify the jurisdiction within wh ich and the terms and conditions subject to which, the certifying authority shall
perform its certification functions.
Note 2: -The Director General of Health Services, Ministry of Health and Family Welfare, Government of India shall
be the authority to dec ide upon cases where any controversy or doubt arises in matters relating to interpretation of the
definitions or classifications or evaluation procedure regarding the said guidelines.
[F. No. P -13013/12/2023 -UDID/IT/Statistics]
RAJEEV SHARMA , Jt. Sec y.
ANNEX URE
Guidelines for Purpose of Assessing the Extent of Specified Disability in a Person Included under the Rights of
Persons with Disabilities Act, 2016 (49 of 2016)
Definition: “Locomotor disability” means a person’s inability to execute distinctive ac tivities associated with
movement of self and objects resulting from affliction of musculoskeletal, nervous system, or both.
SECTION A:
Guidelines for Evaluation of Permanent Physical Impairment (PPI) of Extremities (Upper and Lower
Extremities)
1.1. Gui delines for Evaluation of Permanent Physical Impairment (PPI) of Upper Extremities
(a) The estimation and measurement shall be made when the clinical condition has reached the stage of maximum
improvement from the medical treatment. Normally the time peri od is to be decided by the medical doctor who is
evaluating the case for issuing the PPI Certificate as per standard format of the certificate.
(b) The upper extremity is divided into two components: the arm component and the hand component.
(c) Measurem ent of the loss of function of arm component consists of measuring the loss of range of motion, muscle
strength and co -ordinated activities. I. LOCOMOTOR DISABILITY
(d) Measurement of loss of function of hand component consists of determining the prehension, sensation and
streng th. For estimation of prehension opposition, lateral pinch, cylindrical grasp, spherical grasp and hook grasp have
to be assessed.
(e) The impairment of the entire extremity depends on the combination of the impairments of both components.
(f) Total disa bility % will not exceed 100%.
(g) Disability is to be certified as whole number and not as a fraction.
(h) Disability % is to be stated in relation to that extremity which has been in use in India for the past many years (in
the absence of a generally a greed upon system in India of reflecting Disability % in relation with the whole body).
(i) For Locomotor Disability except Section C (Permanent Physical Impairment in Persons with Amputation),
Temporary Disabilities Certificate will be issued after 6 mon ths of symptoms. For permanent disability, certificate
after 18 years of age, re -assessment every 10 years should be done, where requested by the PwD or recommended by a
subject expert.
1.2.1. ARM (UPPER EXTREMITY) COMPONENT
Total value of the arm compone nt assigned is 90%.
1.2.2. Principles of evaluation of range of motion (ROM) of joints
(a) The value of maximum ROM in the arm component assigned is 90%.
(b) The weightage given to involvement of different joints is as mentioned below:
Shoulder = up to 20%, Elbow = up to 20%, Wrist = up to 10%, Hands = up to 40%
Further calculation is done depending upon the extent of involvement (mild – less than 1/3, moderate – up to 2/3, or
severe – almost total).
If more than one joint of the upper extremity is invo lved, the loss of percentage in each joint is calculated separately as
above and then added together.
1.2.3. Principles of evaluation of strength of muscles:
(a) Strength of muscles can be tested by manual method and graded from 0 -5 as advocated by Medic al Research
Council (MRC), London, UK depending upon the strength of the muscles (Appendix -I).
(b) Loss of muscle power can be given percentages as follows:
(i) The mean percentage of loss of muscle strength around a joint is multiplied by 0.30.
(ii) If loss of muscle strength involves more than one joint the mean loss of percentage in each joint is
calculated separately and then added together as has been described above for loss of range of motion.
1.2.4. Principles of evaluation of coordinated activit ies:
(a) The total value for coordinated activities assigned is 90%.
(b) Ten different coordinated activities should be tested as given in the Form A . (Appendix
II - assessment proforma for upper extremity).
(c) Each activity has been assigned a value o f 9%.
(d) Average normal range of different joints for reference is at Appendix III.
1.2.5. Combining values for the Arm Component:
The total value of loss of function of arm component is obtained by combining the value of loss of ROM, muscle
strength an d coordinated activities, using the combining formula
where a = higher value and b = lower value
1.3.1. HAND COMPONENT:
(a) Total value of hand component assigned is 90%.
(b) The functional impairment of hand is expressed as loss of prehension, lo ss of sensation and loss of strength.
1.3.2. Principles of evaluation of prehension:
Total value of prehension assigned is 30%.
It includes:
(a) Opposition - 8%
- Tested against - Index finger - 2%
- Middle finger - 2%
- Ring finger - 2%
- Little finger - 2%
(b) Lateral pinch - 5%
- Tested by asking the patient to hold a key between the thumb and lateral side of index finger.
(c) Cylindrical grasp - 6%
-Tested for
(i). Large object of approx. 4 inches size - 3%
(ii). Small object of 1 -2 inch size - 3%
(d) Spherical grasp - 6%
- Tested for
(i) Large object of approx. 4 inches size - 3%
(ii) Small object of 1 -2 inch size - 3%
(e) Hook grasp - 5%
- Tested by asking the patient to lift a bag.
1.3.3. Principles of Evaluat ion of Sensations:
(a) Total value of sensation in hand is 30%.
(b) It shall be assessed according to the distribution given below:
(i) Complete loss of sensation
Thumb ray - 9%
Index finger - 6%
Middle finger - 5%
Ring finger - 5%
Little finger - 5%
(ii) Partial loss of sensation:
Assessment should be made according to percentage of loss of sensation in thumb/finger(s).
1.3.4. Principles of Evaluation of Strength
(a) Total value of strength is 30%.
(b) It includes:
(i) Grip strength - 20%
(ii) Pinch strength - 10%
Strength of hand should be tested with hand dynamometer or by clinical method (grip method).
10% weightage to be added in case of persons with involvement ofdominant upper extremity (mostly right upper
extremity) due to acquired co nditions (diseases/ injuries etc.) and not to those with congenital anomalies, conditions,
loss, or deformities.
For shortening of upper extremity, addition weightage is as follows:
First 1" - No additional weightage
For each 1" beyond the first 1" - 2% additional weightage.
Additional weightage –
A total of up to 10% additional weightage can be given to following accompanying factors if they are significant,
continuous and persistent despite standard treatment.
(i) Deformity:
In functional position - 3%
In non -functional position - 6%
(ii) Pain:
Mild (slightly interfering with function) - 3%
Moderate (interfering with function) - 6%
Severe (grossly interfering with function) - 9%
(iii) Loss of sensations:
Partial Loss – up to 6%
Complete Loss - 9%
(iv) Complication s:
Superficial complications - 3%
Deep complications - 6%
Total % of PPI will not exceed 100% in any case.
Disability % is to be stated in relation to that extremity which has been in use in India for the past many years (in the
absence of a generally a greed upon system in India of reflecting in relation with the whole body).
Disability % is to be mentioned as whole number, and not as a fraction.
1.3.5. Combining values of hand component:
The final value of loss of function of hand component is obtain ed by summing up values of loss of prehension,
sensation and strength.
1.3.6. Combining values for the Extremity:
Value of impairment of arm component and impairment of hand component is to be computed by using the combining
formula:
where a = hi gher value and b = lower value.
2. Guidelines for Evaluation of Permanent Physical Impairment in Lower Extremity
The measurement of loss of function in lower extremity is divided into two components, namely, mobility and
stability components.
2.1.1. MOB ILITY COMPONENT
Total value of mobility component is 90% which includes range of movement (ROM) and muscle strength.
2.1.2. Principles of Evaluation of Range of Movement:
(a) The value of maximum range of movement in mobility component is 90%
(b) The a ppropriate weightage given to involvement of proximal and middle joints is as follows:
Hip= up to 35%, Knee= up to 35%, Ankle= up to 20%,
Further calculation is done depending upon the extent of involvement (mild – less than 1/3, moderate – up to 2/3, or
severe – almost total).
If more than one joint of the limb is involved the mean loss of ROM in percentage should be calculated in relation to
individual joint separately and then added together to calculate the loss of range of motion and strength in rel ation to
that particular limb.
2.1.3. Principle of Evaluation of Muscle Strength:
(a) The value for maximum muscle strength in the extremity is 90%.
(b) Strength of muscles can be tested by Manual Method and graded 0 -5 depending upon the residual strengt h in the
muscle group.
(c) Manual muscle strength grading can be given percentage as below:
Numerical Score of Muscle Power Qualitative Score Loss of strength in %
0 Zero 100
1 Trace activity 80
2 Poor 60
3 Fair 40
4 Good 20
5 Normal 0
(d) Mean pe rcentage of muscle strength loss around a joint is multiplied by 0.30 to calculate loss in relation to limb.
(e) If there has been a loss muscle strength involving more than one joint the final value is then computed by adding
up as has been described abo ve.
2.1.4. Combining values for mobility component: The value of loss of ROM and loss of muscle strength is to be
computed with the help of the combining formula:
where a = higher value, b = lower value.
2.2. Stability Component
(a) Total value of the stability component is 90%
(b) It shall be tested by clinical method as given in Form B (Assessment Proforma for lower extremity) in
Appendix II. There are Ten activities, which need to be tested, and each activity has a value of nine per cent (9%).
The percentage valued in relation to each activity depends upon the percentage of loss stability in relation to each
activity.
2.3. Extra Points
Extra points (% of impairment) are given for deformities, pain, contractures, loss of sensations and shortening etc.
For Shortening (true shortening and not apparent shortening):
First 1/2" - Nil
Every 1/2" beyond first 1/2" - 4%
Maximum extra points for associated problems such as deformity, pain, contractures etc. to be added are 10%
(excluding shortening).
(a) Deformity
In functional position - 3%
In non -functional position - 6%
(b) Pain
Mild (slightly interfering with function) - 3%
Moderate (interfering with function) - 6%
Severe (grossly interfering with function) - 9%
(c) Loss of sensation
Partial Loss - 6%
Complete Loss - 9%
(d) Complications
Superficial complications - 3%
Deep complications - 6%
SECTION B:
3. Guidelines for Evaluation of Permanent Physical Impairment of the Spine
Basic guidelines:
3.1. Permanent physical impairment cau sed by spinal injuries or deformity may change over the years, the certificate
issued in relation to spine may have to be reviewed as per the standard guidelines for disability certification.
3.2. Permanent physical impairment is stated in relation to the Spine which has been in use in India for the past many
years (in the absence of a generally agreed upon system in India of reflecting in relation with the whole body).
3.3 TRAUMATIC LESIONS
3.3.1 Cervical Spine Injuries:
No. Cervical Spine Injuries
Percentage of PPI in
relation to the Spine
i. 25% or more compression of one or two adjacent vertebral bodies with No involvement
of posterior elements, No nerve root involvement, moderate Neck rigidity and
persistent Soreness. 20%
ii. Posterior ele ment damage with radiological evidence of moderate
dislocation/subluxation including whiplash injury.
A) With fusion healed, No permanent motor or sensory changes
B) Persistent pain with radiologically demonstrable instability.
10%
25%
iii. Severe Disloca tion:
A) Fair to good reduction with or without fusion with no residual motor or sensory
involvement
B) Inadequate reduction with fusion and persistent radicular pain
10%
15%
3.3.2 Cervical Intervertebral Disc Lesions:
No. Cervical Intervertebral Disc Lesions Percentage of PPI In relation to
Spine
i. Treated case of disc lesion with persistent pain but no neurological
deficit 10%
ii. Treated case of disc lesion with pain and instability 15%
3.3.3 Thoracic and Thoracolumbar Spine Injuries:
No. Thoracic and Thoracolumbar Spine Injuries Percentage of PPI In relation to
Spine
i. Compression of less than 50% involving one vertebral body with no
neurological manifestation 10%
ii. Compression of more than 50% involving single vertebra or more
with involvement of posterior elements, healed, no neurological
manifestations persistent pain, fusion indicated 20%
iii. Same as (ii) with fusion, pain only on heavy use of back 15%
iv. Radiologically demonstrable instability with fracture o r fracture
dislocation with persistent pain 30%
3.3.4 Lumbar and Lumbosacral Spine: Fracture
No. Lumbar and/or Lumbosacral Spine Fracture
Percentage of PPI In relation to
Spine
i. Compression of 25% or less of one or two adjacent Vertebral bodies ,
No definite pattern, No neurological Deficit 10%
ii. Compression of more than 25% with disruption of Posterior
elements, persistent pain and stiffness, healed with or without
fusion, inability to lift more than 10 kgs. 20%
iii. Radiologically dem onstrable instability in low lumbar or
Lumbosacral spine with pain 30%
3.3.5 Intervertebral Disc lesion:
No. Intervertebral Disc lesion Percentage of PPI In relation to
Spine
i. Treated case with persistent pain 10%
ii. Treated case with pers istent pain and instability 20%
iii. Treated case with persistent pain and activities of lifting moderately
modified 25%
iv. Treated case with persistent pain and stiffness, aggravated by heavy
lifting necessitating modification of all activities r equiring heavy
weightlifting 30%
4. Non -Traumatic Lesions:
Scoliosis and/or Kyphoscoliosis:
4.1. Scoliosis is a condition in which an individual's spine has lateral, or side to side curvature. Although scoliosis is a
three -dimensional deformity, on an x-ray, scoliosis curves can often look like a simple “S” or a “C” shape.
4.2. Scoliosis is defined with radiographs that include a standing x -ray of the entire spine antero -posterior view, as
well as the lateral view. Curve magnitude is measured in degree s using the Cobb method.
A straight spine has a curve of 0º; any curve greater than 10º is considered scoliosis.
Between 0ºand 10º is considered "postural asymmetry" which is not true scoliosis.
The lateral radiograph is used to determine the thoracic k yphosis (or round back appearance) and the amount of
lumbar lordosis (swayback).
4.3. In general, the severity of the scoliosis depends on the degree of the curvature and whether it adversely affects
functioning of vital organs, specifically the lungs and heart.
The percentage of Permanent Physical Impairment is calculated as follows:
Group Cobb Angle % of permanent physical impairment
Group 1 10-20 degrees 1 to 5%
Group 2 21-30 degrees 6 to 9%
Group 3 31-50 degrees 10 to 19%
Group 4 51-75 degrees 20 to 29%
Group 5 76-100 degrees 30 to 39%
Group 6 101-125 degrees 40 to 60%
Group 7 126 degrees or greater 61 to 70%
4.4. A person with scoliosis or kyphoscoliosis should be assessed for cardiorespiratory limitations if present.
Additional weighta ge in % of permanent is to be given according to severity of involvement as assessed clinically or
relevant investigations mentioned in the Guidelines under respective section.
4.5. In cases with scoliosis of severe type cardiopulmonary function tests and percentage deviation from normal shall
be assessed by one of the following simple methods whichever seems more reliable clinically at the time of
assessment. The value thus obtained shall be added by combining formula.
(a) Chest Expansion
Chest expansio n is a simple, inexpensive, and non -invasive clinical/bedside test for assessing chest mobility. Its intra -
rater and inter -rater reliability have been largely demonstrated in healthy populations and in individuals with
respiratory disease. A correlation be tween chest expansion and lung function has been reported in subjects with
ankylosing spondylitis, pneumothorax, pleural effusion, asbestos -related pleural fibrosis, and chest wall distortion.
Chest expansion is to be measured using a measuring tape at 2 d ifferent levels of the rib cage. The anatomical markers
used to define upper chest expansion are the third intercostal space at the level of the clavicular line and the spinous
processes of the fifth thoracic vertebrae. To define lower chest expansion, the tip of the xiphoid process and the
spinous process of the tenth thoracic vertebrae are used as markers.
Instructions are given to the subjects and the procedure is demonstrated to ensure adequate understanding. The 2
measurements of chest diameter are tak en at the end of deep inspiratory and expiratory manoeuvres. Upper and lower
chest expansions are obtained by subtracting the inspiratory diameter from the expiratory diameter, according to the
designated anatomical markers. Subjects are sitting with their arms at their sides, with the trunk and chest uncovered.
The examiner performs 1 measurement of upper chest expansion and then 1 measurement of the lower chest
expansion consecutively, holding the measuring tape at both ends with thumb and index finger ar ound the subject’s
body. The measuring tape has to be snug but not tight.
In the absence of another standardised universally acceptable method with respect to chest expansion and the extent of
physical impairment, the following is proposed as it has been i n use for past many years.
No. Maximum Chest Expansion %Permanent Physical Impairment
1. More than 4 cm Nil
2. 3 cm. to 4 cm. 5
3. 2 cm. to less than 3 cm 10
4. 1 cm. to less than 2 cm 15
5. Less than 1 cm. 20
(b) Counting in a single breath:
It is a simple non -invasive clinical/bedside screening test sometimes used to assess respiratory muscle strength. It is
performed by inhaling maximally and counting as far/high a number as possible in normal voice in a single breath.
Two attempts may be record ed following a one -minute rest in between measurements. It may be useful when formal
Vital Capacity measurement is difficult or not possible.
In the absence of a standardised universally acceptable method with respect to single breath count, the following is
proposed as it has been in use for past many years.
No. Single breath count (SBC) % Permanent Physical Impairment
1 More than 40 Nil
2. 31 to 40 5
3. 21 to 30 10
4. 11 to 20 15
5. 5 to 10 20
6. Less than 5 25
The additional weightage is to be a dded using combining formula:
where a = higher value, b = lower value.
4.6. Torso Imbalance:
In addition to the above PPI should also be evaluated in relation the torso imbalance.
In the absence of a standardised universally acceptable method with respect to torso imbalance, the following is
proposed as it has been in use for past many years.
The torso imbalance should be measured by dropping a plumb line from C7 spine and measuring the distance of
plumb line from gluteal crease.
No. Deviation of Plumb line %of Permanent Physical Impairment
1. Up to 1.5 cm 4
2. 1.6 – 3.0 cm 8
3. 3.1 – 5.0 cm 16
4. 5.1cm or more 32
No. Head Tilt over C7 spine %of Permanent Physical Impairment
1. Up to 15⁰ 4
2. More than 15⁰ 10
Associated Problems as given below: To be added directly but the total value of PPI in relation to trunk should
not exceed 100%.
(a) Pain
No. Extent of Activity (ADL*) Limitation %ofPermanent Physical Impairment
1. Mild limitation of ADLs 4
2. Moderate limitation of ADLs 6
3. Severe limitation of ADLs 10
* ADL - Activities of Daily Living
(b) Cosmetic Appearance:
- no obvious disfiguration with clothes on - Nil
- mild disfigurement - 2%
- severe disfigurement - 4%
(c) Leg Length Discrepancy:
- First1/2" shortening - Nil
- Every1/2" beyond first1/2" - 4%
(d) Neurological deficit - Neurological deficit should be calculated as per established method of evaluation of PPI in
such cases. Value thus obtained should b e added using the combining formula.
4.7. Kyphosis:
Kyphosis is a larger -than-normal forward bend in the spine, most commonly in the upper back. The normal range of
thoracic kyphosis (according to the Scoliosis Research Society) is between 20° -40°, and an y curvature higher than 40°
is considered abnormal.
Evaluation should be done on the similar guidelines as used for scoliosis stated above with the following
modifications:
Spinal Kyphotic Deformity Permanent Physical Impairment
Less than 40⁰ Nil
41-50⁰ 10%
51-60⁰ 20%
61-70⁰ 30%
71-80⁰ 40%
81-90⁰ 50%
91-100⁰ 60%
4.8. Torso Imbalance - Plumb line dropped from external ear normally falls at ankle level. The deviation from
normal should be measured from ankle anterio r joint line to the plumb line.
Distance from ankle anterior joint line to the plumb
line % of permanent physical impairment
Less than 5 cm Up to 4%
5 to 10 cm Up to 8% depending on distance
10 to 15 cm Up to 16% depending on distance
More than 15 cm Up to 32% depending on distance
It is added directly.
4.9. Miscellaneous conditions:
Those conditions of the spine which cause stiffness and pain etc. but are not listed above are rated as follows:
No. Condition % of permanent physical
impairment
1. Subjective symptoms of pain, no involuntary muscle spasm, not
substantiated by demonstrable structural pathology Nil
2. Pain, persistent muscles spasm and stiffness of spine, substantiated by mild
radiological changes, and regular need for treatment (medi cations and non -
pharmacological measures) 20
3. Same as ii. above with moderate radiological changes and regular need for
treatment (medications and non -pharmacological measures) 25
4. Same as ii. above with severe radiological changes involving any one of
the regions of spine and regular need for treatment (medications and non -
pharmacological measures, interventions) 30
5. Same as iv. above involving the whole spine and regular need for treatment
(medications and non -pharmacological measures, interventi ons) 40
SECTION C:
5. Guidelines for Evaluation of Permanent Physical Impairment in Persons with Amputation (Amputees):
5.1. Basic Guidelines:
(a) In cases of multiple amputees, the % of permanent impairment is to be computed by using the combining fo rmula:
Where a = higher value, b = lower value.
(b) If the stump is unfit for satisfactorily fitting the prosthesis, an additional weightage of 5% should be added to the
value.
(c) Any complication in form of stiffness of proximal joint, neuroma, infection, etc., should be given up to a total of
10% additional weightage.
(d) Involvement of dominant upper limb (right upper limb in majority of individuals) in acquired amputation should
be given 10% additional weightage.
5.2. Upper Limb Amputations:
No. Level of Upper Limb Amputation % of permanent physical impairment
1. Fore-quarter amputation 100
2. Shoulder Disarticulation 90
3. Trans Humeral (Above Elbow) up to upper 1/3 of arm 85
4. Trans Humeral (Above Elbow) up to lower 1/3 of arm 80
5. Elbow disarticulation 75
6. Trans Radial (Below Elbow) up to upper 1/3 of forearm 70
7. Trans Radial (Below Elbow) up to lower 1/3 of forearm 65
8. Krukenberg Operation or Amputation 65
9. Wrist disarticulation 60
10. Hand through carpal bones 55
11. Partial amputation of hand (at the level of shafts of all the
metacarpals); thumb intact 30
12. Thumb through C.M. or though 1st MC joint 30
13. Thumb disarticulation through metacarpophalangeal Joint or
through proximal phalanx 25
14. Thumb disartic ulation through inter phalangeal joint or
through distal phalanx 15
15. Amputation through Proximal phalanx or Disarticulation
through MP joint of Index finger 15
Amputation through Proximal phalanx or Disarticulation
through MP joint of Middle finger 5
Amputation through Proximal phalanx or Disarticulation
through MP joint of Ring finger 3
Amputation through Proximal phalanx or Disarticulation
through MP joint of little finger 2
16. Amputation through Middle phalanx or Disarticulation 10
through PIP joint of Index finger
Amputation through Middle phalanx or Disarticulation
through PIP joint of Middle finger 4
Amputation through Middle phalanx or Disarticulation
through PIP joint of Ring finger 2
Amputation through Middle phalanx or Disarticul ation
through PIP joint of little finger 1
17. Amputation through Distal phalanx or disarticulation through
DIP joint of Index finger 5
Amputation through Distal phalanx or disarticulation through
DIP joint of Middle finger 2
Amputation through Dist al phalanx or disarticulation through
DIP joint of Ring finger 1
Amputation through Distal phalanx or disarticulation through
DIP joint of little finger 1
5.3. Lower Limb Amputations:
No. Level of Lower Limb Amputation % of permanent physical
impairm ent
1. Hind quarter 100
2. Hip disarticulation 90
3. Trans Femoral (Above knee) up to upper 1/3 of thigh 85
4. Trans Femoral (Above knee) up to lower 1/3 of thigh 80
5. Through knee 75
6. Trans Tibial (Below Knee) up to upper 1/3 of leg 70
7. Trans Tibial (Below Knee) up to lower 1/3 of leg 60
8. Through ankle 55
9. Syme's 50
10. Up to mid -foot (proximal to tarso -metatarsal joints level) 40
11. Up to forefoot (distal to tarso -metatarsal joints level) 30
12. Loss of all toes 20
13. Loss of first toe 10
14. Loss of second toe 4
15. Loss of third toe 3
16. Loss of fourth toe 2
17. Loss of fifth toe 1
6. Guidelines for Evaluation of Permanent Physical Impairment of Congenital deficiencies of the extremities
Congenital limb deficiency simply me ans the partial or total absence of a limb at birth. These may be sporadic or
syndromic.
A variety of limb classification systems have been used over the years. The current and accepted form of classification
that has been adopted internationally since 19 98 is the ISPO (International Society for Prosthetics and Orthotics)
classification system.
Common examples of congenital limb deficiencies include congenital femoral deficiency, proximal focal femoral
deficiency and congenital tibial deficiency in lower limb and congenital radial longitudinal deficiency (radial club
hand) and congenital ulnar longitudinal deficiency in upper limb.
TRANSVERSE DEFICIENCIES
6.1. Functionally congenital transverse limb deficiencies are comparable to acquired amputations and can be called
synonymously as congenital amputation. However, in some cases revision of amputation is required to fit in
prosthesis.
6.2. The transverse limb deficiencies therefore should be assessed on basis of the guidelines applicable to the
evaluatio n of PPI in cases of amputees as given in the preceding chapter.
Level % of permanent physical
impairment
Transverse deficiency Rt. Arm complete (shoulder disarticulation) 90%
Transverse deficiency at thigh complete (hip disarticulation) 90%
Transverse deficiency Proximal Upper arm (Above elbow) 85%
Transverse deficiency at lower thigh (Above knee, Lower 1/3) 80%
Transverse deficiency forearm complete (elbow disarticulation) 75%
Transverse deficiency lower forearm (Below Elbow) 65%
Transverse defici ency carpal complete (wrist disarticulation) 60%
Transverse deficiency Metacarpal complete (Disarticulation through carpal bones) 55%
LONGITUDINAL DEFICIENCIES
Basic Guidelines
6.3. In cases of longitudinal deficiencies of limbs, due consideration shal l be given to functional impairment.
6.4. In upper limb, loss of ROM, loss muscular strength and hand functions like prehension, etc shall be tested while
assessing the case for PPI.
6.5. In lower limb clinical method of stability component and shortenin g of lower limb shall be given due weightage.
6.6. Apart from functional assessment, the lost joint/part of body should also be valued as per distribution given in the
Guidelines for Evaluation of PPI in upper extremity and lower extremity amputation. The values so obtained shall be
added with the help of combining formula.
6.7. In cases of loss of single bone in forearm the evaluation shall be based on the principles of evaluation of Arm
component which include Evaluation of ROM, Muscle strength -and coor dinated activities. The values so obtained
shall be added together with the help of combining formula.
6.8. In cases of loss of single bone in leg the evaluation should be based on the principles of evaluation of mobility
component and stability component s of the lower extremity. The values obtained should be added together with the
help of combining formula.
SECTION D:
Guidelines for Evaluation of permanent physical impairment in persons with Club Foot and a few other
locomotor conditions
7. Club Foot:
Clubfoot is a common deformity of the foot. It is most often noticed at birth. However, similar looking deformity can
be seen in a few other conditions as well.
Deformity may be mild, moderate, or severe.
Severity of Clubfoot Deformity is commonly asse ssed in clinical settings in India using a Scoring method developed
by Shafique Pirani. It is based on six clinical signs (three signs of hind foot and three signs of mid -foot). Each sign is
scored 0 (normal), 0.5 (mildly abnormal) or 1 (severely abnormal) . The amount of deformity is “scored” and recorded
as “Hindfoot Score”, “Midfoot Score” and as a summed “Total Score”.
The Hindfoot Score (HS) is the sum of the scores for Posterior Crease (PC), Rigid Equinus (RE), and Empty Heel
(EH). HS value is a measu rement of contracture posteriorly from 0 (no deformity) to 3 (severe deformity).
The Midfoot Score (MS) is the sum of the scores for Medial Crease (MC), CLB, and Lateral Head of Talus (LHT).
MS value is measurement of contracture medially from 0 (no defor mity) to 3 (severe deformity).
The Total Score (TS) is a sum of the HS and MS. TS value is measurement of overall deformity from 0 (no deformity)
to 6 (severe deformity).
In the absence of a standardised universally acceptable method with respect to clu b foot, the following scoring system
using Pirani Severity Score is proposed for calculating permanent physical impairment as it has been in use for the
past few years.
Total Score % of Permanent Physical Impairment
0 0
0.5 3
1 7
1.5 10
2 14
2.5 17
3 20
3.5 24
4 27
4.5 31
5 35
5.5 37
6 40
Note:
(i) Disability is to be certified as whole number and not as a fraction.
(ii) Disability is to be certified in relation to that lower extremity as it has been in use in India for the past many
years (in the ab sence of a generally agreed upon system in India of reflecting in relation with the whole
body).
(iii) . In cases with bilateral involvement, % PPI is calculated for each side and then combining formula is used.
(iv) Total disability % will not exceed 100%.
8.1. Lymphoedema:
Chronic lymphedema is an important condition regardless of if it is classified as primary or secondary and cannot
simply be described as an accumulation of protein -rich fluid. It is a chronic degenerative and inflammatory process
affecting th e soft tissues, skin, lymph vessels and nodes and may result in severe and often disabling swelling.
Lymphedema may present in the extremities, trunk, abdomen, head and neck and external genitalia and can develop
anytime during the course of a lifetime in primary cases; secondary cases may occur immediately following the
surgical procedure or trauma, within a few months, a couple of years, or twenty years or more after treatment.
8.2. Its severity is assessed and graded as follows:
• Grade 1 : 5% to 10% i nterlimb discrepancy in volume or circumference at point of greatest visible difference;
swelling or obscuration of anatomic architecture on close inspection; pitting oedema.
• Grade 2 : More than 10% to 30% interlimb discrepancy in volume or circumference at point of greatest visible
difference; readily apparent obscuration of anatomic architecture; obliteration of skin folds; readily apparent deviation
from normal anatomic contour.
• Grade 3 : More than 30% interlimb discrepancy in volume; lymphorrhea; gr oss deviation from normal anatomic
contour; interfering with activities of daily living.
• Grade 4 : Progression to malignancy (e.g., lymphangiosarcoma); amputation indicated; disabling lymphedema.
In the absence of a standardised universally acceptable m ethod with respect toLymphoedema, the following method is
proposed for calculating permanent physical impairment as it has been in use for the past few years.
Lymphoedema Grade Permanent Physical Impairment
1 Less than 10%
2 10 – 39% depending on severi ty within this grade
3 40 – 50% depending on severity within this grade
4 51 to 70% depending on severity within this grade
Note:
(i) Disability is to be certified as whole number and not as a fraction.
(ii) Disability is to be certified in relation to that ex tremity as it has been in use in India for the past many years
(in the absence of a generally agreed upon system in India of reflecting in relation with the whole body).
(iii) . In cases with bilateral/ more than one limb involvement, % PPI is calculated for ea ch limb and then
combining formula is used.
(iv) Total disability % will not exceed 100%.
9. Charcot’s Joint
Charcot joint or neuropathic joint, or Charcot arthropathy is a progressive condition of the musculoskeletal system that
is characterized by joint d islocations, pathologic fractures, and debilitating deformities.
The hallmark deformity associated with this condition is midfoot collapse, described as a “rocker -bottom” foot.
Charcot arthropathy results in progressive destruction of bone and soft tissu es at weight bearing joints; in its most
severe form, it may cause significant disruption of the bony architecture.
Charcot arthropathy can occur at any joint; however, it occurs most commonly in the lower extremity, at the foot and
ankle.
The Charcot fo ot has been documented to occur as a consequence of various peripheral neuropathies; however,
diabetic neuropathy has become the most common etiology.
Numerous classification systems exist for the categorization of the Charcot foot according to the severi ty/location and
complexity of the condition. Most of the classification systems of Charcot foot include radiographic and anatomical
findings; however, Lee C Roger’s classification is based on the stage/complexity and location of the Charcot foot
deformity, which offers a more prognostic view of the condition. In addition, this classification system depicts the risk
factors for amputation with increasing severity and location of Charcot foot deformity.
In the absence of a standardised universally acceptable method with respect to Charcot’s Joint, the following method
is proposed for calculating permanent physical impairment using Lee C Roger’s classification as it has been in use for
the past few years.
Location and Stage Forefoot Midfoot Rearfoot/Ankle
Acute Charcot without deformity 15% 20% 25%
Charcot with deformity 20% 25% 30%
Charcot with deformity and ulceration 30% 35% 40%
Charcot with deformity and osteomyelitis 40% 45% 50%
Note:
(i) Disability is to be certified as whole number and not as a fract ion.
(ii) Disability is to be certified in relation to that extremity as it has been in use in India for the past many years
(in the absence of a generally agreed upon system in India of reflecting in relation with the whole body).
(iii) . In cases with bilateral l imb involvement, % PPI is calculated for each limb and then combining formula is
used.
(iv) Total disability % will not exceed 100%.
SECTION E:
10. Guidelines for Evaluation of Locomotor Disability due to chronic Neurological conditions.
Basic Guidelines:
10.1. Assessment in neurological conditions is not the assessment of disease but the assessment of its effects, i.e.,
clinical manifestations.
10.2. These guidelines shall only be used for central and upper motor neurone lesions.
10.3. For assessment o f lower motor neurone lesions, muscular disorders and other locomotor conditions, methods of
evaluation as mentioned above will be used.
10.4. Normally any neurological assessment for the purpose of certification has to be done six months after the onset
of disease; however, exact time period is to be decided by the Medical Doctor who is evaluating the case and has to
recommend the review of certificate as given in the standard format of certificate.
10.5. Total percentage of physical impairment in any ne urological condition shall not exceed 100%.
10.6. In mixed cases the highest score will be taken into consideration. The lower score will be added to it using the
combining formula:
where a = higher value, b= lower value.
10.7. Additional rating of 10% will be given for involvement of dominant upper extremity in cases with acquired
condition.
10.8. Additional weightage up to 10% can be given for loss of sensation in each extremity but the total physical
impairment should not exceed 100%.
Motor Sys tem Disability
11. Stroke
11.1. There are a number of Scales reported in scientific literature. The modified Rankin Scale (mRS) is one of these
scales that is commonly used for measuring the degree of disability or dependence in the daily activities of p eople
who have suffered a stroke or other causes of neurological disability.
It is a single item, global outcomes rating scale. The Scale runs from 0 -6, running from perfect health without
symptoms to death.
11.2 In the absence of a standardised univers ally acceptable method with respect to Stroke, the following method is
proposed for calculating permanent physical impairment using the modified Rankin Scale (mRS) as it has been in use
for the past few years.
mRS
Score Features % of Permanent Physical
Impairment
0 No symptoms at all Nil
1 No significant disability despite symptoms; able to carry out all usual
duties and activities Up to 30% depending on the
extent of deficits
2 Slight disability: unable to carry out all previous activities, but able to look
after own affairs without assistance 40%-50%
3 Moderate disability: requiring some help, but able to walk without
assistance 51% - 60%
4 Moderately severe disability: unable to walk without assistance and unable
to attend to own bodily needs withou t assistance 61% - 80%
5 Severe disability: bedridden, incontinent and requiring constant nursing
care and attention more than 80%
6 Dead Not applicable
12. Other Chronic Neurological Disabilities/Conditions
12.1. Parkinsonism
Parkinsonism is an imp ortant disorder of movement due to involvement of basal ganglia, extra -pyramidal system. It
commonly manifests as motor symptoms and non -motor symptoms. Common motor symptoms include tremors,
rigidity, slowness of movements, imbalance, gait impairments etc . These impairments are often noticed to progress
over time with increasing disability. A large number of scales exist in clinical domains, but there is little universal
agreement on the best choice of scale for disability evaluation.
In the absence of a s tandardised universally acceptable method with respect to Parkinsonism related disability, the
following simple method, adapted from some important published guidelines, is proposed for calculating permanent
physical impairment:
Criteria for Rating Impairm ents of the Upper Extremity:
No. Features % of Permanent Physical
Impairment
1. Individual can use the involved extremity for ADLs involving gross
movements but has difficulty with fine movement control of fingers
(digital dexterity) Nondominant limb = 20 %
Dominant limb = 30%
2. Individual can use the involved extremity for basic ADLs, can grasp
and hold objects with difficulty, but lacks fine movement control of
fingers (digital dexterity) Nondominant limb = 30%
Dominant limb = 40%
3. Individual can use the involved extremity only as a gross assist in basic
ADLs Nondominant limb = 40%
Dominant limb = 50%
4. Individual cannot use the involved extremity for basic ADLs Nondominant limb = 50 %
Dominant limb = 60%
Criteria for Rating Impairments of the Stat ion, Gait and Lower Extremities:
No. Features % of Permanent Physical
Impairment
1. Individual can rise to standing position, can walk unassisted but has difficulty
with elevations, stairs, uneven surfaces, getting up from chairs with more
depth, does not fall, and/or walking long distances Up to 30%
2. Individual can rise to standing position, can walk some distance with difficulty
and without assistance, but is limited to level surfaces, falls are uncommon Up to 40%
3. Individual rises and maintains s tanding position with difficulty, cannot walk
without assistance, sometimes falls down Up to 50%
4. Individual cannot stand without help, mechanical support, and/or an assistive
device, falls are frequent Up to 60%
In a person with significant involvemen t of upper and lower limbs, the percentage of disability is calculated by
applying the combining formula:
where a = higher value, b= lower value.
The disability is expressed in relation to whole body.
12.2. Extent of Sensory Deficit Physical Impair ment
In the absence of a standardised universally acceptable method with respect to disability due to sensory deficits, the
following simple method, adapted from some important published guidelines, is proposed for calculating permanent
physical impairmen t:
No. Features % of Permanent Physical Impairment
1. Anaesthesia Up to 10% for each limb
2. Hypoaesthesia Depending upon % of loss of sensation
3. Paraestheis Up to 30% depending upon loss of sensation
Extent of Bladder function Deficit Percentage of physical impairment
Mild (Hesitancy, Frequency) * 20% (Picture in Mobile)
Moderate (Precipitancy)* 30%
Severe (occasional but recurrent incontinence) * 40%
Very severe (Retention/Total incontinence) * 50%
* Definitions of bladder dysfunction
Terms Definitions
Frequency Increased frequency is defined as those children who void 8 per day.
Decreased frequency is defined as those children who void 3 per day
Urgency Sudden and unexpected experience of an immediate and compelling need to void. This
term is not applicable before the attainment of bladder control
Hesitancy Difficulty in initiating voiding when the child is ready to void
Precipitancy Also known as urinary incontinence.
Defined as involuntary leakage of urine
Austin PF et al The standar dization of terminology of lower urinary tract function in children and adolescents:
Update report from the standardization committee of the International Children's Continence Society. Neurourol
Urodyn. 2016.
12.3. Ataxia (Cerebellar)
Refer to chronic ne urological disorders (25.4.2)
Disability is expressed in relation to whole body
SECTION F:
13. Spinal Cord Injuries
13.1. The resulting impairment and disability after Spinal Cord Injury (SCI) is typically significant and devastating.
The determination o f impairment and disability after SCI is usually straightforward and may be accomplished by
general categorization of an individual’s neurologic and functional level. Although secondary medical difficulties,
such as pressure ulcers, spasticity, deep venous thrombosis, heterotopic ossification, myopathic pain syndromes,
restrictive pulmonary compromise etc., which may impact both impairment and disability, can arise at any time after
SCI, neurologic and functional abilities are typically stabilized by twelve months.
13.2. Documenting impairments in a person with an SCI is best determined by performing a standardized neurological
examination as endorsed by the International Standards for Neurological Classification of Spinal Cord Injury
(ISNCSCI) Patients. Pe rsons with Spinal Cord Injury are graded on the ASIA (American Spinal Injury Association)
Impairment Scale.
The ASIA Impairment Scale:
Level - Type Features
A = Complete No motor or sensory function is preserved in the S4 -S5 segments.
B = Incomplete Sensory but not motor function is preserved below the neurological level and includes
intact S4 -S5 segments (light touch or pinprick at S4 -S5 or deep anal sensation) and no
motor function is preserved more than three levels below the motor level on either sid e of
the body.
C = Incomplete Motor function is preserved below neurological level, and more than half of the key
muscles below the neurological level have a muscle grade
D = Incomplete Motor function is preserved below neurological level, and at least h alf (half or more) of the
key muscles below the neurological level have a muscle grade >3.
E = Normal If sensation and motor function as tested with the ISNCSCI are graded as normal in all
segments, and the patient had prior deficits, then the AIS grade i s E. Someone without a
SCI does not receive an AIS grade.
13.3. The individuals with SCI may be categorized into one of the four main categories for the purpose of neurogenic
bladder related disability evaluation and certification:
Bladder dysfunction ma y be assessed under
Extent/Natureof Bladder function Deficit Percentage of physical impairment
Mild (Hesitancy, Frequency) * 20%
Moderate (Precipitancy)* 30%
Severe (occasional but recurrent incontinence) * 40%
Very severe (Retention/Total incontinenc e) * 50%
* Definitions of bladder dysfunction
Terms Definitions
Frequency Increased frequency is defined as those children who void 8 per day
Decreased frequency is defined as those children who void 3 per day
Urgency Sudden and unexpected experien ce of an immediate and compelling need to void. This
term is not applicable before the attainment of bladder control
Hesitancy Difficulty in initiating voiding when the child is ready to void
Precipitancy Also known as urinary incontinence.
Defined as in voluntary leakage of urine
Neurological status:
No. Diagnostic Category % of permanent physical
impairment
1. Tetraplegia (or more specifically, bilateral severe loss of upper
extremity function plus the presence of paraplegia
Neurological level C5 or ab ove
Neurological level C6 or below
Up to 90%
Up to 80%
2. Paraplegia
Neurological level T6 or above
Neurological level between T7 and T10
Neurological level T11 or T12
Up to 70%
Up to 65%
Up to 60%
3. Cauda equine syndrome without bladder or bowel dy sfunction Up to 40%
4. Cauda equine -like syndrome with bowel or bladder impairment such
as lumbosacral plexopathies Up to 60%
(a) Tetraplegia replaced the term quadriplegia in 1992.
(b) Terms such as tetraparesis, quadriparesis, paraparesis are to be a voided.
(c) Additional weightage of up to 20% is given for presence of significant neuropathic pain, spinal deformity,
spasticity, contracture, heterotopic ossification, pressure ulcer etc. depending on severity, and added to the permanent
physical impair ment % computed as above.
(d) Total disability % will not exceed 100%.
(e) Disability is to be certified as whole number.
(f) Disability is expressed in relation to whole body.
SECTION G:
14. Acid Attack Victims
14.1. Definition "acid attack victims" means a person disfigured due to violent assaults by throwing of acid or similar
corrosive substance.
14.2. Acid attacks cause chemical burns. Acids cause coagulation necrosis with precipitation of proteins. They can
cause lifelong bodily disfigurement. T he medical effects of acid attacks are generally extensive. Acids used in acid
attacks may be acetic acid, carbolic acid, chromic acid, formic acid, sulphuric acid, nitric acid, hydrochloric acid,
hydrofluoric acid, oxalic acid, phosphoric acid etc. The se verity of the damage depends on the concentration of the
acid and the time before the acid is thoroughly washed off with water or neutralized with a neutralizing agent. The
acid can rapidly eat away skin, the layer of fat beneath the skin, and in some case s even the underlying bone.
14.3. Impairments resulting from acid burns are not restricted to the skin. Often, more than one system is involved,
such as skin, musculoskeletal, respiratory, vision etc. Scarring represents a special type of disfigurement. S cars affect
sweat glands, hair growth, and nail growth, and cause pigment changes or contractures and may affect loss of
performance and cause impairment. The lymphatic system can be affected in the lower or upper extremity, causing
chronic swelling of the leg and feet, or the arm and hand respectively.
14.4. Since majority of acid attacks are aimed at the face, eyelids and lips may be completely destroyed, the nose and
ears severely damaged. Acid can quickly destroy the eyes, blinding the victim. The eyel ids may no longer close, the
mouth may no longer open, and the chin may become welded to the chest.
14.5. Given below are the frequently noted physical consequences of acid attacks:
Skull: May be partly destroyed or deformed. Hair is often lost.
Forehead : Skin may shrink, as though stretched tightly, and be scarred.
Ears: Shrivelled up and deformed. Deafness may occur immediately or later. Cartilage in the ear is usually partly or
totally destroyed, exposing the victim to future infection and hearing los s.
Eyes: Direct acid contact or acid vapors can damage eyes, causing blindness. Even if the eyes survive the acid attack,
they remain vulnerable to other threats which can cause blindness during the victim’s recovery. Eyelids may have
been burned off, or may be deformed by scarring, leaving the eyes to dry up and go blind. This is very difficult to
prevent.
Nose: Shrunken and deformed. Nostrils may close completely because the cartilage is destroyed.
Cheeks: Scarred and deformed.
Mouth: Shrunken and nar rowed and may lose its shape. Lips may be partly or totally destroyed. Lips may be
permanently flared, exposing the teeth. Movement of the lips, mouth and face may be impaired. Eating can be
difficult.
Chin: Scarred and deformed. The scars may run downwar d, welding the chin to the neck or chest.
Neck: Often badly damaged. It may have a thick cord of scarred flesh running down from the chin to the upper chest,
or a wide, heavily scarred area on one side of the neck. Victim may be unable to extend the neck, or the head may
constantly lean to one side.
Chest: Often badly scarred. The chest may have narrow lines of scars or wide patches of scars from acid splashes or
drips. In girls and young women, the development of their breasts may be stopped, or their br easts may be destroyed
completely.
Shoulder: May be badly scarred, especially around the underarm, which may limit the victim’s arm movement. In
some cases, one or both of the victim’s upper arms may be stuck like glue to the sides of their body.
14.6. Disability in acid attack victims is to be estimated by taking into consideration extent of damage in terms of area
and depth, as is in cases of thermal injuries (burns).
Good colour photography with multiple views of the area of involvement enhances the d escription.
Every acid burn, regardless of the depth of injury, heals with some element of contracture. Contractures may require a
series of staged surgical procedures before optimal function and cosmesis are achieved.
Scar tissue is less tolerant of the everyday stress imposed on it than normal skin.
An extremity can be considered impaired even if it has a full range of motion because of a poor quality of skin after
the chemical burn - skin that is thin and fragile, likely to ulcerate easily even with mi nor injuries.
Even people who have received skin grafts can have intolerance to sunshine, heat, cold or sensation.
14.7. Restriction of normal movement by contracture is not limited to the extremities. Scars around the trunk also can
become tight and sti ff. When a scar occurs over the trunk or anterior chest, severe and chronic postural changes can
result which may cause secondary spinal deformity or altered respiratory function. A badly scarred perineum or
buttocks may make sitting in one position for pr olonged period painful and difficult.
14.8. In the absence of a standardised universally acceptable method with respect to disability arising as a result of
Acid Attacks, the following method is proposed for calculating permanent physical impairment as it has been in use
for the past few years.
Part of the body affected Deficit % of permanent physical
impairment
Scalp and vault including
forehead Disfigurement alone
Deformity or full thickness loss 5% 10%
Eyebrows (Ri ght & Left) Loss of part of one or both
Total loss of one or both 3% each 5% each
Eye lids -
Upper
Lower
Skin disfigurement alone
Deformity or full thickness loss
Skin disfigurement alone
Deformity or full thickness loss
3% each 5% eac h
2% each 3% each
External Ear (Pinna) Skin disfigurement alone
Deformity due to full thickness involvement of
skin and cartilage without obliteration of meatus
Deformity due to full thick ness involvement of
skin and cartilage with obliteration of meatus 2% each 3% each
5% each
Nose Skin cover disfigurement alone
Deformity due to full thickness involvement with
both nares (nostrils) 3% 5%
Lips Skin cover disfigurement one lip alone
Deformity or full thickness loss of one lip alone
Deformity due to involvement of both lips leading
to contracture 3%
5%
10%
Cheek and lateral area of face Skin disfigurement
Deformity or full thickness loss 5% each side 10% each side
Neck Skin cover disfigurement
Deformity due to involvement of skin, muscle, or
deeper tissue 5% 10%
Breast (Female) Only skin cover disfigurement Deformity resulting
in loss of function due to involvement of 5% each
i) skin, areola & nipple
ii) Skin, areo la, nipple & parenchyma
10% each 15% each
Front of trunk & abdomen
excluding breast Only skin cov er disfigurement Deformity or full
thickness loss 5% 10%
Total back Only skin cover disfigurement Deformity or full
thickness loss 5% 10%
Groins Only skin cover disfigurement Deformity or full
thickness loss 2% each 5% each
Buttocks Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Genitalia Skin loss resulting in mild deformity Severe
contracture of orifices or sloughing of urethra or
severe deformi ty of penis 7% 20%
Thigh Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Lower leg Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Foot Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Upper arm Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Forearm Only skin cover disfigurement Deformity or full
thickness loss 3% each 5% each
Hand Only skin cover disfigurement Deformity or full
thickness loss 5% each 10% each
Mouth: Sometimes, the lips may be partly or totally destroyed, exposing the teeth. Eating and speaking can become
difficult. Up to 20%
Esophagus: Inhalation of acid vapors creating upper digestive tract problems Up to 20%
Respiratory involvement: Acid vapors creating upper respiratory problems Up to 20%
In addition, any significant respiratory function impai rment, if present, is to be assessed based on the guidelines as
given in respective section and weightage added depending on severity of involvement.
14.9. The total % of permanent impairment/disability will not exceed 100%.
SECTION H:
15. Cerebral Palsy affected Persons with disabilities.
15.1. Definition - "cerebral palsy" means a group of non -progressive neurological condition affecting body
movements and muscle coordination, caused by damage to one or more specific areas of the brain, usually occurring
before, during or shortly after birth.
15.2. In the absence of any universally accepted method or scale, the Gross Motor Function Classification System
(GMFCS) is proposed for use while evaluating and certifying cerebral palsy affected individuals. It is based on self -
initiated movement, with emphasis on sitting, transfers, and mobility. This is a five -level classification system, and the
primary criterion is that the distinctions between levels must be meaningful in daily life. Distinctions are based on
functional limitations, the need for hand -held mobility devices (such as walkers, crutches, or canes) or wheeled
mobility, and to a much lesser extent, quality of movement.
For assessment of extent of permanent physical impairments in Cerebral Palsy, the following method was proposed a
few years ago, and has been used in India since January 2018.
GMFCS
Level Description of Mobility status % of permanent
physical impairment
Level I • Can walk indoors and outdoors and climb stairs without using hands for
support
• Can perform usual activities such as running and jumping
• Has decreased speed, balance and coordination Less than 40%
Level II • Can climb stairs with a railing
• Has difficulty with uneven surfaces, inclines or in crowds
• Has only minima l ability to run or jump 40 to 50%
Level III • Walks with assistive mobility devices indoors and outdoors on level
surfaces
• May be able to climb stairs using a railing
• May propel a manual wheelchair and need assistance for long distances or
uneven surfaces 51 to 60%
Level IV • Walking ability severely limited even with assistive devices
• Uses wheelchairs most of the time and may propel own power wheelchair
• Standing transfers, with or without assistance 61 to 79%
Level V • Has physical imp airments that restrict voluntary control of movement
• Ability to maintain head and neck position against gravity restricted
• Impaired in all areas of motor function
• Cannot sit or stand independently, even with adaptive equipment
• Cannot independen tly walk but may be able to use powered mobility 80% or more
Manual Ability Classification System (MACS)
15.3. The Manual Ability Classification System (MACS) describes how persons with cerebral palsy (CP) use their
hands to handle objects in daily activ ities. MACS describes five levels. The levels are based on the person’sself -
initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday
life.
15.4. MACS spans the entire spectrum of functional l imitations found among persons with cerebral palsy and covers
various sub -diagnoses.
15.5. Level I include persons with minor limitations, while persons with severe functional limitations will usually be
found at levels IV and V. MACS levels are stable ov er time.
15.6. The certifying medical authority needs to know the following to use MACS:
For assessment of extent of permanent physical impairments in Cerebral Palsy, the following method was proposed a
few years ago, and has been used in India since Jan uary 2018.
The person’s ability to handle objects in important daily activities, for example during play and leisure, eating and
dressing, is to be considered as per the following scale:
Level I. Handles objects easily and successfully. At most, limitati ons in the ease of performing manual asks requiring
speed and accuracy. However, any limitations in manual abilities do not restrict independence in daily activities.
Level II. Handles most objects but with somewhat reduced quality and/or speed of achieve ment. Certain activities
may be avoided or be achieved with some difficulty; alternative ways of performance might be used but manual
abilities do not usually restrict independence in daily activities.
Level III. Handles objects with difficulty; needs hel p to prepare and/or modify activities. The performance is slow
and achieved with limited success regarding quality and quantity. Activities are performed independently if they have
been set up or adapted.
Level IV. Handles a limited selection of easily ma naged objects in adapted situations. Performs parts of activities with
effort and with limited success. Requires continuous support and assistance and/or adapted equipment, for even partial
achievement of the activity.
Level V. Does not handle objects and has severely limited ability to perform even simple actions. Requires total
assistance.
MACS Level Features % of permanent physical impairment
Level I Handles objects easily and successfully. 20%
Level II Handles most objects but with somewhat reduced
quality and/or speed of achievement. 30%
Level III Handles objects with difficulty; needs help to
prepare and/or modify activities. 40%
Level IV Handles a limited selection of easily managed
objects in adapted situations. 55%
Level V Does not handle obj ects and has severely limited
ability to perform even simple actions. 70%
Note:
(i) In the absence of a universally accepted method, in individuals with disability due to Cerebral Palsy, both
GMFCS and MACS are used, and the final extent of disability is com puted by applying the combining
formula as given below and also frequently mentioned in these guidelines.
(ii) In a person with cerebral palsy, other than problems of movement or posture, there may be other limitations
such as visual impairment, hearing impair ment, speech impairment, epilepsy, mental sub -normality (low
IQ) etc. These are assessed separately as per the guidelines and the final disability % calculated using the
combining formula:
where a = higher value, b = lower value.
(iii) Total permanent ph ysical impairment/disability % will not exceed 100%.
(iv) Disability is to be certified in relation to the whole body.
SECTION I:
16. Leprosy Cured Persons with disabilities
16.1. Definition: "leprosy cured person" means a person who has been cured of lepro sy but is suffering from -
(i) loss of sensation in hands or feet as well as loss of sensation and paresis in the eye and eyelid but with no manifest
deformity.
(ii) manifest deformity and paresis but having sufficient mobility in their hands and feet to e nable them to engage in
normal economic activity.
(iii) extreme physical deformity as well as advanced age which prevents him/her from undertaking any gainful
occupation, and the expression "leprosy cured" shall be construed accordingly.
16.2. WHO grading of disability in Leprosy:
Highest grade for each eye or hand or foot = 2.
E= Eyes, H= Hands, F= Feet
Maximum EHF sum score = 12.
Grade Eyes Hands Feet
0 No eye problem due to leprosy; no
evidence of visual loss No anaesthesia, no visible
deformity or damage No anaesthesia, no visible
deformity or damage
1 Eye problem due to leprosy present, but
vision not severely affected as a result of
these (vision: 6/60 or better; can count
fingers at 6 metres). Anaesthesia present, but no
visible deformity or da mage Anaesthesia present, but no
visible deformity or damage
2 Severe visual impairment (vision worse
than 6/60, inability to count fingers at 6
metres). Also includes lagophthalmos,
iridocyclitis and corneal opacities Visible deformity or damage
present (such as
cracks/wounds, claw
fingers, wrist drop,
contractures, amputation
etc.) Visible deformity or damage
present (such as
cracks/wounds, claw toes,
foot drop, contractures,
amputation etc.)
16.3. For sensory testing of hands and feet, light touch (j ust enough to indent the skin very slightly) of the tip of ball
point pen is recommended.
16.4. For testing loss of corneal sensation, light touch of the clean cotton wisp from the lateral side is recommended. It
is also to be noted whether blinking of th e eyes is normal or not.
16.5. Muscle power is tested clinically by Voluntary Muscle testing of commonly examined peripheral nerves and
graded as per the Medical Research Council, London Scale.
EHF (Eyes, Hands, Feet) Grade Score is calculated.
The high er the Score, greater the Disability.
Maximum EHF Score possible to assign is 12.
EHF Score % of permanent physical impairment
0 to 1 Up to 20%
2 to 3 21 to 40%
4 to 5 41 to 60%
6 to 7 61 to 70%
8 to 9 71 to 80%
10 to 11 81 to 90%
12 91 to 100%
16.6. In the absence of a standardised universally acceptable method with respect to disability in Leprosy -cured
individuals, the following method is proposed for calculating permanent physical impairment as it has been in use for
the past few years.
16.7. In a leprosy cured person with involvement of dominant upper extremity (mostly right hand), additional 10%
weightage is to be given.
Total permanent physical impairment/disability % will not exceed 100%.
In a leprosy curedpersons, review may be necessary in a few persons if there is a significant change in the clinical
condition, after a specified period, such as 5 to 10 years or as decided by the Specified Disability Experts or the
designated Medical Board.
SECTION J:
17. Guidelines for Evaluation of P PI in cases of Short Stature/Dwarfism:
17.1. Definition: "Dwarfism" means a medical or genetic condition resulting in an exceptionally small person. It is
often defined as an adult height of less than 147 centimetres (4 feet 10 inches), regardless of gende r/sex.
17.2. The most common and recognisable form of dwarfism in humans (comprising 70% of cases) is achondroplasia,
a genetic disorder whereby the limbs are diminutive. Growth hormone deficiency is responsible for many other
cases. There are also several other less common causes.
The evaluation of a short statured person shall be considered irrespective of whether it is of proportionate variety (both
the arms and torso are unusually small) or disproportionate variety (either short limbs or a short torso) . Intelligence is
usually normal, and most persons with dwarfism have a nearly normal life expectancy. People with dwarfism can
usually bear children, though there may be additional risks in some cases to the mother or child depending on the
underlying con dition or degree of dwarfism.
17.3. In the absence of a standardised universally acceptable method with respect to Dwarfism/Short Stature related
disability, the following method is proposed for calculating permanent physical impairment as it has been in u se for
the past few years.
Every 1" vertical height reduction shall be valued as 4% permanent physical impairment in relation to whole body.
Associated skeletal deformities such as contractures or deformities shall be evaluated separately and total percen tage
of both shall be added by combining formula.
Height of the Adult % of permanent physical impairment
4 feet 10 inches or more Nil
4 feet 9 inches 4%
4 feet 8 inches 8%
4 feet 7 inches 12%
4 feet 6 inches 16%
4 feet 5 inches 20%
4 feet 4 inche s 24%
4 feet 3 inches 28%
4 feet 2 inches 32%
4 feet 1 inch 36%
4 feet 40%
3 feet 11 inches 44%
3 feet 10 inches 48%
3 feet 9 inches 52%
3 feet 8 inches 56%
3 feet 7 inches 60%
3 feet 6 inches 64%
3 feet 5 inches 68%
3 feet 4 inches 72%
3 feet 3 inches 76%
3 feet 2 inches 80%
3 feet 1 inch 84%
3 feet 88%
2 feet 11 inches 92%
2 feet 10 inches 96%
2 feet 9 inches or less 100%
SECTION K:
18. Muscular Dystrophy
18.1. Definition: "Muscular dystrophy" means a group of hereditary genetic m uscle disease that weakens the muscles
that move the human body and persons with muscular dystrophy have incorrect and missing information in their
genes, which prevents them from making the proteins they need for healthy muscles. It is characterised by pr ogressive
skeletal muscle weakness, defects in muscle proteins, and the death of muscle cells and tissue.
18.2. In the absence of a standardised universally acceptable method with respect to extent of disability due to
Muscular Dystrophy, the following me thod is proposed for calculating permanent physical impairment as it has been
in use for the past few years.
After detailed clinical examination, each of the features namely, weakness, contractures, scoliosis, cardiac or
pulmonary involvement are evaluated and disability is computed based on the criteria for each of these and added to
the locomotor disability component, using the combining formula:
where ‘a’ is the higher value and ‘b’ is the lower value).
Disability is to be expressed in relation t o the whole body.
Total % of disability will not exceed 100%.
Due to progressive nature of this disease, in general, review may be necessary after a specified period, such as 5 years
or more or as decided by the Specified Disability Experts or the design ated Medical Board, or as per the Law.
18.3 Medical Authority*:
18.3.1 The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as
notified by the State Government shall be the head of the certification board for the purpose of certification of
locomotor disability including cerebral palsy, leprosy cured, dwarfism, acid attack victims and muscular dystrophy.
The Medical Board shall comprise of:
I. Medical Superintendent or Chief Medical Officer or Civil Surgeon,
II. Specialist in Physical Medicine and Rehabilitation (PMR), or a Specialist in Orthopaedics if specialist in
PMR is not available,
III. One specialist doctor as nominated by the Medical Superintendent or the Chief Medical Officer as per the
condition of the pers on with disability.
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
18.3.2. Common instruments required for certification of locomotor disability: The most importan t resource is
the knowledge and skill of the Members/Experts involved in the process. However, a few items listed below may also
be required:
a. A measuring tape for measuring – vertical height of the person, degree of chest expansion, shortening of an
extremity, or difference in girth of a limb etc.,
b. Goniometers – small, medium, and large, for measuring range of motion at different joints,
c. Hand -held dynamometer,
d. A clean cotton piece for testing corneal sensation,
e. A ball point pen for testi ng sensory deficit e.g., in leprosy -cured person,
f. X-ray films, e.g., in cases with spinal deformity, amputation, club foot, congenital limb deficiency, fractures,
arthritis etc Uploaded by
19.1. Definition . –Visual impairment
(a) "blindness" means a con dition where a person has any of the following conditions, after best
correction —
(i) Total absence of sight; or
(ii) Visual acuity less than 3/60 (or less than 10/200) by Snellen's chart in better eye with best possible
corrections or
(iii) Limitation of field of visio n subtending an angle of less than 10 degree in better eye
II. VISUAL IMPAIRMENT
(b) "Low - vision "means a condition where a person has any of the following conditions, namely: —
(i) Visual acuity less than 6/18 (or 20/60) up to 3/60 (or 10/200) by Snellen’s chart in the better eye wit h
best possible corrections or
(ii) Limitation of the field of vision subtending an angle of less than 40 -degree up to10 -degree in better
eye (Refer to table no 1).
19.2. Nature of Certificate: The medical authority will decide whether status of disability is t emporary or permanent.
Disability certificate should be issued only in case of permanent Disability. The benefits like reservation in
employment, education etc should be restricted to permanently disabled persons only. A permanently disabled person
whose c ondition is likely to change in future should be reassessed. The temporary disability certificate shall be issued
for visual disabilities when the visual disability is only due to cataract and CSCR (Central serous chorio -retinopathy)
19.3. Visual Impairmen t Certification Criteria and Gradation
Vision assessments should be done after best possible correction (medical, surgical or usual/conventional
spectacles). The Ophthalmologist shall circle the vision Status and the Percentage Impairment and mark the
Disability category accordingly as under:
TABLE NO .-1
For visual acuity the line should be read completely in case of partial line read, online below that line
should be taken for visual acuity.
If during the assessment, the pat ients’ visual responses are variable or inconsistent with the previous
records or clinical findings or diagnosis, then the permanent disability certificate should not be issued, and
further investigations should be carried out.
Matrix Table No -2
Left Eye Vision [Best Corrected Visual Acuity (BCVA)]) Better eye
Best Corrected Worse eye
Best
Corrected Per cent
Impairment Disability
category
Visual acuity: 6/6 to 6/18 6/6 to 6/18 0% 0
6/24 to 6/60 10% 0
Less than 6/60 to 3/60 20% I
Less than 3/60 No Light
Perception 30% II (One eyed
person)
Visual acuity: 6/24 to6/60
Or
Visual field less than 40 degrees
upto 20 degrees around center of
fixation or hemianopia involving
macula 6/24 to6/60 40% III a (low vision)
Less than 6/60 to 3/60 50% III b (l ow vision)
Less than 3/60 to No
Light Perception 60% III c (low vision)
Visual acuity: Less than 6/60 to
3/60
Or
Visual field less than20 degrees
upto10 degrees around centre
of fixation Lessthan6/60to3/60 70% III d (low
vision)
Lessthan3/60toNoLight Perception 80% III e (low
vision)
Visual acuity: Less
than 3/60 to 1/60
Or
Visual field less than10 -degree
around centre of fixation Less than 3/60 to No Light Perception 90% IVa
(Blindness)
Visual acuity:
Only HMCF
Only Light Perception,
No Light Perce ption Only HMCF
Only Light Perception,
No Light Perception 100% IV b
(Blindness)
6/6 to6/18 6/24 6/36 6/60 3/60 2/60 1/60 HMCF to
PL-
6/6 to 6/18 0% 10% 10% 10% 20% 30% 30% 30%
6/24 10% 40% 40% 40% 50% 60% 60% 60%
6/36 10% 40% 40% 40% 50% 60% 60% 60%
6/60 10% 40% 40% 40% 50% 60% 60% 60%
3/60 20% 50% 50% 50% 70% 80% 80% 80%
2/60 30% 60% 60% 60% 80% 90% 90% 90%
1/60 30% 60% 60% 60% 80% 90% 90% 90%
HMCF to
PL- 30% 60% 60% 60% 80% 90% 90% 100%
Yellow -Right eye is better eye; Brown -Left eye is better eye
Percentage of disability is m arked inside the box corresponding to the visual acuity for both eyes.
Matrix Table no -3
Field of Vision around the centre of fixation
Left Eye
<40°to20° <20°to10°
<10°
<40° to 20° 40% 50% 60%
<20° to 10° 50% 70% 80%
<10° 60% 80% 100%
Yellow - Right eye is better eye; Brown - Left eye is better eye (only better eye Fields to be taken into account for
determining the percentage
19.4. Medical Authority*: The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other
equivalent authorit y as notified by the State Government shall be the head of the certification medical authority for the
purpose of certification of hearing disability and speech and language disability. The certification medical authority
shall comprise of:
I. Medical Superin tendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as
notified the State Government
II. Ophthalmologist,
III. Ophthalmologist/Optometrist*/ Ophthalmic Assistant*
*4 years degree from recognized university
Note* - In view of shorta ge of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if requir ed, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member. Right Eye Vision [Best Corrected Visual Acuity (BCVA)] Right Eye
IIIA. HEARING IMPAIRMENT (DEAF AND HARD OF HEARING)
20.1.1 Definition:
(a) “Deaf” mean persons having 70 Db hearing loss in speech frequen cies in both ears;
(b) "Hard of hearing” means person having 60Db to 70db hearing loss in speech frequencies in both ears;
20.1.2. Conditions for which Hearing Disability Certificate can be issued:
(a) Sensori neural Hearing Loss
(b) In cases of permanent/ irreversible mixed hearing loss (e.g. Congenital malformations of external and middle ear,
Otosclerosis, Ossicular Chain Discontinuity, Chronic Otitis Media etc.) assessment of hearing disability will be done
if no improvement in hearing ability after six months of completion of medical -surgical treatment/ use of appropriate
assistive devices.
(c) In cases of permanent/ irreversible conductive hearing loss (e.g.,Congenital malformations of external and middle
ear, Otosclerosis, Ossicular Chain Discontinuity , Chronic Otitis Media etc.), assessment of hearing disability will be
done if no improvement in hearing ability after six months of completion of medical -surgical treatment/use of
appropriate assistive devices.
20.2. Guidelines for Assessment:
20.2.1. Mea surement Air Conduction Thresholds (ACT):
(a) ACT is to be measured using standard Pure Tone Audiometry by an Audiologist for Right Ear and Left Ear
separately.
(b) In case of non -reliable Air Conduction Thresholds, additional tests are recommended such as Immittance,
Speech audiometry and Auditory Brainstem Response (ABR)/ Auditory Steady State Response (ASSR) Testing.
Apart from Click evoked ABR, Tone Burst/Frequency specific Chirp evoked ABR and/ or ASSR using frequency
specific Chirp stimuli should be u sed to determine estimated hearing thresholds for 500 Hz, 1000Hz, 2000Hz and
4000Hz for Right ear and Left ear separately.
(c) Measuring ACT may be difficult in children aged 3 -5 years. In such cases, Conditioned Pure Tone
audiometry/Visual Reinforcement A udiometry (VRA) shall be conducted. ABR & / Auditory Steady State
Response (ASSR) testing can be advised for the estimation of ACT in infant and young children. Apart from Click
evoked ABR, Tone Burst/Frequency specific Chirp evoked ABR and/or ASSR using f requency specific Chirp
stimuli should be used to determine estimated hearing thresholds for 500 Hz, 1000Hz, 2000Hz and 4000Hz for
Right ear and Left ear separately.
20.2.2. Computation of Percentage of Hearing Disability:
(a) Monaural Percentage of Heari ng Disability
(i) Calculate Pure tone average of ACT for 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz for Right Ear and Left ear
separately (whenever there is no response at any frequency ACT is to be considered as 95dB).
(ii) Monaural percentage of hearing disabilit y is to be calculated as per the ready reckoner given below separately
for Right Ear and Left Ear.
Monaural PTA in dB % of Disability Monaural PTA in dB % of Disability
0 to 25 0 61 41.71
26 1 62 43.42
27 1 63 45.13
28 1 64 46.84 III. HEARINGIMPAIRMENT AND
SPEECH & LANGUAGE DISABILITY
29 1 65 48.55
30 1 66 50.26
31 1 67 51.97
32 1 68 53.68
33 1 69 55.39
34 2 70 57.1
35 3 71 58.81
36 4 72 60.52
37 5 73 62.23
38 6 74 63.94
39 7 75 65.65
40 8 76 67.36
41 9 77 69.07
42 10 78 70.78
43 11 79 72.49
44 12 80 74.2
45 13 81 75.91
46 14 82 77.62
47 15 83 79.33
48 16 84 81.04
49 17 85 82.75
50 18 86 84.46
51 19 87 86.17
52 20 88 87.88
53 21 89 89.59
54 22 90 91.3
55 23 91 93.01
56 24 92 94.72
57 25 93 96.43
58 26 94 98.14
59 27 95 100
60 40
III.B. SPEECH AND LANGUAGE DISABILITY
20.3.1. Definition: "Speech and language disability" means a permanent disability arising out of conditions
such as laryngectomy or aphasia affecti ng one or more components of speech and language due to organic or
neurological causes
20.3.2. Conditions affecting Speech Components for which Speech Disability certificate can be issued
(i) Laryngectomy (assessment for disability after completion of trea tment)
(ii) Glossectomy (assessment for disability after completion of treatment)
(iii) Bilateral vocal cord paralysis (assessment for disability 9 -12 months’ post onset) Percentage of Hearing Disability =
(Better ear% of hearing disability X 5) + (Poorer ear% of hearing disability)
(iv) Maxillofacial anomalies (assessment for disability after completion of medical -surgical treatment, use/fitting of
prosthetic devices and one year of regular documented speech therapy intervention by RCI Registered Speech
Language Pathologists).
(v) Dysarthria (assessment for disability after completion of one year of regular documente d speech therapy
intervention by RCI Registered Speech Language Pathologists).
(vi) Apraxia of Speech (assessment for disability after completion of one year of regular documented speech therapy
intervention by RCI Registered Speech Language Pathologists).
20.3.3. Computation of percentage Speech Disability
(a) Speech Intelligibility Test :
The verbal output of person should be evaluated using Perceptual Speech Intelligibility Rating Scale [AYJNISHD (D),
2022 ](Appendix IV )and percentage of Speech Intelligib ility Affected ( SIA) to be measured based on score as the
table given below:
Point
Scale Description of Speech Sample Percentage of
Disability
1 Normal 0-15
2 Can understand without difficulty; however, feel speech is normal 16-30
3 Can understand with little effort occasionally need to ask for repetition 31-39
4 Can understand with concentration and effort especially by sympathetic listener;
require a minimum of two or three repetition. 40-55
5 Can understand with difficulty and concentration by fa mily but not others 56-75
6 Can understand with effort if content is known 76-89
7 Cannot understand at all even when content is known 90-100
(b)Voice Test
Consensus Auditory Perceptual Evaluation of Voice (CAPE -V) (Appendix -V) or Dysphonia Severity Ind ex (DSI) can
be used for measuring percentage of Overall Voice Clarity Affected (OVCA) which includes roughness, breathiness,
strain, pitch, and loudness. Average score to be given weighted for the percentage of overall voice clarity affected:
Score Percen tage of overall voice clarity affected ( OVCA )
1 0-15
2 16-30
3 31-39
4 40-55
5 56-75
6 76-89
7 90-100
Percentage of Speech Disability=
2 x Upper range of percentage of SIA+ Upper range of percentage of OVCA
20.4.1. Conditions affecting Langua ge Components for which Language Disability certificate can be issued
Aphasia
20.4.2 . Language Test
Western Aphasia Battery (WAB) in Indian languages is to be administered post six months of the
onset of the stroke and Aphasia Quotient (AQ) is to be calcul ated as per standard procedure by a
Speech Language Pathologist.
20.4.3. Percentage of Language Disability
Percentage of Language Disability can be computed directly from the ready reckoner given below by
intersection of value for Number in Tens place in W AB score and Number in Unit place in WAB
score. For example, if the AQ is 56, intersection of 6 (in column) and 5 (in row) is 40. The Percentage
of Language Disability is 40%.
Number in
Tens Place in
WAB
Score Number in Unit Place in WAB Score
0 100 98.9 97.8 96.8 95.7 94.6 93.6 92.5 91.4 90.4
1 89.3 88.2 87.2 86.1 85.0 84.0 82.9 81.8 80.8 79.7
2 78.6 77.6 76.5 75.4 74.4 73.3 72.2 71.2 70.1 69.0
3 68.0 66.9 65.8 64.8 63.7 62.6 61.6 60.5 59.4 58.4
4 57.3 56.2 55.2 54.1 53.0 52.0 50.9 49.8 48.8 47.7
5 46.6 45.6 44.5 43.4 42.4 41.3 40.0 39.2 38.1 37.1
6 36.0 34.9 33.9 32.8 31.7 30.7 29.6 28.5 27.5 26.4
7 25.3 24.3 23.2 22.1 21.1 20 18.9 17.9 16.8 15.7
8 14.7 13.6 12.5 11.5 10.4 09.3 8.3 07.2 06.1 05.1
9 4.0 2.9 1.9 0.8 00.0 00.0 00.0 00.0 00.0 00.0
20.5. Medical Authority*:
The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified
by the State Government shall be the head of the certification medical authority for the purpose of certification of
hearing disability and speech & language disability. The certification medical authority shall comprise of:
I. Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority.
II. ENT Specialist
III. Audiologist/Speech Language Pathologist/ Audiometric Assistant (Should be BASLP or equivalent which is
RCI recognised).
In addition to above,
In case of Speech disability due to "Dysarthria" and "Apraxia of Speech" and Language Disability due to
“Aphasia” , Neurologist/Paediatric Neurologist shall be included in the Medical Board.
In case of Speech Disability in the "Maxillofacial anomalies", Plastic Surgeon/Oral -Maxillofacial
Surgeon/Paediatric Surgeon shall be included in the Medical Board.
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board m ay, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
21.1 Neuro -developmental Disorders
Neuro -developmental disorders are diverse group of chronic disorders. They begin at any time during the development
process (including conception, birth, and growth) up to 22 years of age and last throughout an individual’s lifetime.
Children with neuro -developmental disorders have difficulty in any of the domains: Language and speech, Motor
skills, Behaviour, Memory, Learning including Intellectual Disability (ID), Specific Learning Disorder (SLD) and
Autism Spectrum Disorder (ASD).
Section A: Intellectual Disability
21.2. Definition
Intellectual disability is defined as a condition characte rized by significant limitations both in intellectual functioning
(reasoning, learning, problem -solving) and in adaptive behavior, with onset in the developmental period, and which
covers a range of daily social skills and skills required for activities of daily living. The term intellectual disability will
be reserved for children with age 5 years and above (≥5 years). The children with a similar disability and an age less
than 5 years will be designated as having Global Developmental Delay.
21.3. Screenin g
All children on follow -up in a healthcare facility should be screened for developmental delay/ intellectual disability.
The identified children/ adolescent should be referred for a detailed assessment to a pediatrician/ psychiatrist. They
should also be screened for associated co -morbidities, viz., hearing impairment, visual impairment, locomotor
impairment, epilepsy and other co -morbid conditions (Figure 1).
21.4. Diagnosis
The screened children should be referred to clinical/ rehabilitative psychologis ts for assessment.
Age less than 5 years
Children less than 5 years of age should be assessed for VSMS (( Appendix -VI) and the VSMS profile should be used
to decide for the domains involved. These children, if having impairment on VSMS will be diagnosed as Global
Developmental Delay.
Age ≥5 years
Children ≥5 years should be assessed for adaptive functioning and IQ. The tools which have to be used for adaptive
functioning and IQ may be VSMS/BKT/WISC -IV/MISIC/WISC/NIEPID Indian Test of Intelligence ( Appendix VII
& Appendix –VIIIa, b, c ).
21.5. Disability Calculation
Irrespective of age, the disability calculation will be done based on the VSMS score. The disability levels will be as
under:
Serial Number VSMS Score Disability Percentage
IV. Intellectua l Disability, Specific Learning Disorder,
Autism Spectrum Disorder
a. 0-20: Profound 100% disability
b. 21 to 35: Severe 90% disability
c. 36 to 54: Moderate 75% disability
d. 55-69: Mild 50% disability
e. 70-84: Borderline 25% disability
21.6. Age for certification
The minimum age for certification will be one (01) completed year. Children above one year and up to the age of 5
years shall be given a diagnosis of Global Developmental Delay. Children above the age of 5 years shall be given a
diagnosis and certificate of Intellectual Disability.
21.7. Medical Authority*
The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified
by the State Government shall be the head of the Medical Board. The Authority shall comprise of:
a. Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as
notified by the State Government
b. Pediatrician or Pediatric Neurologist (where available) or Developmental Pediatrician (where available) or
physician (if age >18 years)
c. Psychiatrist or Child and Adolescent Psychiatrist (wherever available)
d. Clinical or Rehabil itation Psychologist
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
21.8. Validity of Certificate:
Temporary certificate for children less than 5 years:
Below the ag e of five years, a temporary certificate will be issued with a diagnosis of Global Developmental Delay.
This certificate will be valid till the age of 05 years.
For children more than 5 years:
The certificates issued at ≥5 years of age will have the following validity
(a) Children with 80% or more disability: After initial certification after the age of 5 years, re -assessment and re -
certification will be done at an age of 18 years. The certificate issued at 18 years or mo re of age will be valid lifelong.
(b) Children with disability <80%: The certificate will mention a renewal age. The certificate issued after the age of
5 years will have to be renewed at the age of 10 years and 18 years. The certificate issued at 18 years or more of age
will be valid lifelong.
Figure 1. Details of assessment and disability calculation for a child with global developmental delay/ intellectual
disability
Section B: Specific Learning Disability
22.1. Definition
Specific learning disabilit ies refers to a heterogeneous group of developmental learning disorders wherein there is a
deficit in processing language, spoken or written, that may manifest itself as a difficulty to comprehend, speak, read,
write, spell, or to do mathematical calculati ons and includes such conditions as perceptual disabilities, dyslexia,
dysgraphia, dyscalculia, dyspraxia, and developmental aphasia.
22.2. Screening
The screening shall be performed by teachers of the public and private school at eight years of age or in Class III,
whichever is earlier. The screening test is illustrated in Form A. The child should be referred for further assessment if
the reply to screening shows three or more answers in “frequently” column.
Every school (public and private) shall have a screening committee headed by the principal of the school. After
applying the screening test, if an anomaly is detected, the teacher should bring it to the notice of principal and
screening committee of the school. The teachers shall interview the parents to assess their involvement and motivation
regarding their child’s education. If the parents are motivated and screening questionnaire suggests specific learning
disability, then child should be referred for further assessment.
The child should be referred to pediatrician/ pediatric Neurologist/ developmental pediatrician/ psychiatrist for
specific learning disability assessment by the principal of the school with the recommendations of the screening
committee endorsed.
22.3. Diagnosis
The diagnosis will re quire a team approach involving a pediatrician (or pediatric neurologist or developmental
pediatrician), psychiatrist (or child and adolescent psychiatrist) and clinical or rehabilitation psychologist (Figure 2).
This would involve three steps:
Step 1: Cli nical Assessment
1(a). Assessment by a pediatrician: The pediatrician (or pediatric Neurologist or developmental pediatrician, where
available) will do the initial assessment. This will involve a detailed clinical examination including neurological
examina tion, and vision and hearing assessment. It has to be ensured that the child has normal visual acuity and
hearing before proceeding to next step. Formal age -appropriate testing tools should be used to assess vision and
hearing.
1(b). Assessment by Psychiat rist: The assessment by Psychiatrist should be done to rule out associated comorbidities
and mimics including emotional and behavioral disorders.
Step 2: IQ Assessment
After the clinical assessments, IQ testing should be performed by child/ clinical psycho logists using MISIC/ WISC -
IV/NIEPID Indian Test of Intelligence/BKT/VSMS (Appendix - VII&VIII). If the IQ is determined to be more than
85, then step 3 will be applied.
Step 3: Specific Learning Disability Assessment
This would involve application of specif ic psychometric tests for diagnosing specific learning disability. National
Institute for Mental Health and Neurosciences (NIMHANS) battery (Appendix -IX). or Grade Level Assessment
Device (GLAD) (Appendix - X) shall be applied for diagnostic test for SLD. T hese tools will be used across all ages
till such time until new scales are developed and validated for older children and adults. A diagnosis of specific
learning disability will be given if all of the following criteria are fulfilled
IQ 85 or more
No vi sion and /or hearing impairment which are likely to affect learning.
No emotional and behavioral disorders mimicking SLD
Presence of adequate opportunity for learning with proper motivation
The child is functioning at 3 standard deviations below the curren t class on NIMHANS battery or
his/ her GLAD score is below 40%, for the child’s current class level.
22.4. Medical Authority*
The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified
by the State Go vernment shall be the head of the Medical Board. The Authority shall comprise of:
I. Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as
notified by the State Government
II. Pediatrician or Pediatric Neurologist ( where available) or Developmental Pediatrician (where available)
III. Psychiatrist or Child and Adolescent Psychiatrist (wherever available)
IV. Clinical or Rehabilitation Psychologist (line)
Note* - In view of shortage of the specialist doctors resulting in huge p endency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (dul y qualified in
the respective medical domain) as a board member.
22.5. Validity of Certificate:
The certification will be done for children aged eight years and above only. The child will have to undergo repeat
certification during the academic year of Cla ss X and academic year of Class XII, if required. The certificate issued at
18 years or more will be valid life -long.
FORM A
Screening for Learning Disability
___________________________________________________
Name of student: _____________ ____________ _
Date of birth: _____________
Class: _____________
Name of School: _____________ _____________
How long has the teacher been familiar with the student: _____________
___________________________________________________
Dear Teacher,
Have you observed in your day -to-day teaching that the student has some of the following difficulties?
Answer with ‘X’ in appropriate column
S. No. Statement Never Some times Frequently
1. Makes mistakes in reading like
- Omits words
- Substitutes words
- Adds words
- Skips li nes
- Reads sentences repeatedly
2. Can answer questions orally but has difficulty in
writing answers
Or
Oral work is better than written work
3. Writes or reads figures or letters in wrong way, for
example, 15 for 51, 6 for 9, b for d
4. Difficulty in differentiating letter sounds for vowels
and blends, example “E” for “I’; “ch” for “sh”;
5. Difficulty in rhyming words and repeating them
6. Reads in past tense, while the text is written in
present tense or vice -versa; example replaces “is”
with “was”
7. Changes the sequence of alphabets while reading;
example says “neerg” instead of “green”
8. Replaces long words with compact one; example
“musim” for “museum”
9. Difficulty in taking notes or copying them from
blackboard and books
10. Confu sion with mathematics symbols (+, -, X,
divide) while solving word problems and
mathematics computation
11. Difficulty in spellings
12. Difficulties with spatial orientation, and direction;
example confusion between left and right, east and
west, up and down etc
13. Misplaces upper and lower case letters, example
BeTTer, n for N, i for I
14. Writes in mirror images; example “ram” - “mar”
*Sometimes: upto 6 -7 times in 2 -3 months
** Frequently: More than 7 times in 2 -3 months
Figure 2. Details o f assessment for a child with specific learning disability
SECTION C: Autism Spectrum Disorder
23.1. Definition
Autism Spectrum Disorder is a lifelong neurological condition typically appearing in the first three years of life that is
marked by pervasive impairments in the areas of social skills and communication, often associated with hyper -or-
hypo -reactivity to sensory input; unusual interest in stereotypical rituals or behaviors; and may or may not be
accompanied by intellectual impairment.
23.2. Diagn osis
The diagnosis of autism spectrum disorder will be established by the DSM -5-based AIIMS -modified INCLEN
diagnostic tool for ASD (Appendix - XI). The Indian Scale of Assessment of Autism will be utilized for the
calculation of disability among children ≥6 years.
23.3. Disability Calculation
Children <6years
All children with an autism spectrum disorder in the age group <6 years will be assessed a nd given the disability of 60
to 79% (Moderate Autism). They will be re -assessed at the age of ≥6 years for severity -based disability calculation as
per Indian Scale of Assessment of Autism (Appendix - XII).
Children/ adolescents ≥6 years
The severity -based disability calculation for autism spectrum disorder will be based on the Indian Scale of Assessment
of Autism. The disability levels will be as per Table 1.
Table 1. Disability percentage for children with autism spectrum disorder
Serial
Number Indian Sca le of Assessment of Autism Score Disability Percentage
a) Mild Autism (ISAA Score 70 to 106) 40 to 59% disability
b) Moderate Autism (ISAA Score (107 to 153) 60 to 79% disability
c) Severe Autism (ISAA Score >153) ≥80% disability
23.4. Medical Authority*:
The Medical Superintendent, Chief Medical Officer, Civil Surgeon, or any other equivalent authority, as notified by
the State Government, shall be the head of the Medical Board. The Board shall comprise of:
I. Medica l Superintendent, or Chief Medical Officer, or Civil Surgeon or any other equivalent authority as
notified by the State Government
II. Pediatrician or Pediatric Neurologist (where available) or Developmental Pediatrician (where available) or
physician if age > 18 years (MD Internal Medicine or Family Medicine)
III. Psychiatrist or Child and Adolescent Psychiatrist (where available)
IV. Psychologist (Clinical/ rehabilitation)
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability as sessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respe ctive medical domain) as a board member.
23.5. Validity of Certificate:
Children <6 years:
For children certified below the age of six years, the certificate will be temporary. These children will need
reassessment between the age of 6 and 7 years for re -certification and calculation of disability.
Children ≥6 years and <18 years:
For children who are more than 6 years and less than 18 years, the validity will be as below:
After initial certification where a disability of > 40% has been certified, reasses sment and re -certification will be done
at the age of 18 years. The certificate issued at 18 years of age will be valid lifelong.
Adolescents ≥18 years:
For patients >18 years, the disability certificate issued after the age of 18 years will be permanent.
24.1. Definition: "Mental Illness" means a substantial disorder of thinking, mood, perception, orientation, or
memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary
demands of life but does not i nclude mental retardation which is a condition of arrested or incomplete development
of mind of a person, specially characterised by sub -normality of intelligence.
24.2. Diagnosis:
A. The examination process will consist of components as required namely, cli nical assessment, IDEAS scale
and/or IQ assessment. V. Mental Illness
B. Indian Disability Evaluation and Assessment Scale (IDEAS) administration ( Appendix - XIII) is to be used
for mental illness (If required).
C. In some cases, where there is suspicion of intellectual deficits or additional intellectual evaluation is required
for any reason, Standardised IQ test may be carried out as per prescribed standards in Intellectual Disability
Guidelines.
D. In cases where the mental behavioural condition requires only IDEAS, then only IDEA S can be administered,
and degree of disability certified.
E. In cases wherein, there is both intellectual disability and mental illness disability, the person may be classified
as having multiple disability and certificate issued accordingly by the responsib le Medical Board.
F. The duration of the mental illness should be determined from the onset of the mental illness. For certifying
permanent disability, a minimum duration of at least two years of mental illness is required.
24.3. Validity of Certificate:
A. For any mental illness with duration of less than two years, only certificate with time validity may be allowed,
the degree depending on the extent of disability. In case the disability is severe or profound, the medical board
may consider permanent certifica tion.
B. For persons with mental illness (PWMI), who have not received standard of care treatment only disability
certificate with time validity up to two years may be issued by the board.
C. The disability board may recommend for treatment from any mental heal th establishment (MHE) and then
may issue permanent disability certificate only after the PWMI has received the treatment for adequate
duration as determined by the Board.
D. Permanent Disability Certification will be issued based on assessment of the residua l disability despite
appropriate evidence -based treatment as documented on medical records
E. Treatment naïve patients of Mental Illness/their caregivers must be advised to seek appropriate treatment to
empower them and advised to seek disability certificatio n of disability despite adequate treatment.
F. For persons with Mental Illness who have taken psychiatric treatment but do not have any treatment records,
disability certificate with time validity may be issued with advice to seek appropriate psychiatric trea tment,
preserve medical records and repeat disability certification after 2 years.
24.4. MEDICAL AUTHORITY*:
The Medical Superintendent, Chief Medical Officer, Civil Surgeon, or any other equivalent authority, as notified by
the State Government, shall be the head of the Medical Board. The Board shall comprise of:
I. Medical Superintendent, or Chief Medical Officer, or Civil Surgeon or any other equivalent authority as
notified by the State Government
II. Psychiatrist
III. Psychiatrist/Physician or RCI registered Clin ical Psychologist/Rehab Psychologist/Psychiatric social worker
(wherever required Psychological Assessment report from RCI registered Psychologist obtained in last three
months).
Note* - In view of shortage of the specialist doctors resulting in huge pende ncy in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (duly qu alified in
the respective medical domain) as a board member.
25.1 Guidelines for Evaluation of Physical Impairments in Neurological Conditions .
Basic Guidelines
1. Assessment in neurological conditions is not the assessment of disease but the assessment of its effects, i.e.,
clinical manifestations. VI. CHRONIC NEUROLOGICAL CONDITIONS
2. These guidelines should only be used for central and upper motor neuron lesions.
3. Normally any neurological assessment for the purpose of certification has to be done six months after the
onset of disease howe ver exact time period is to be decided by the Medical Doctor who is evaluating the case
and reassessment after two years from the first assessment for the permanent certification.
4. Total percentage of physical impairment in any neurological condition shall not exceed 100%.
5. In mixed cases the highest score will be taken into consideration. The lower score will be added to it by the
help of combining formula:
Where a = higher value and b = lower value
6. Additional 10% will be given for involvement of dom inant upper extremity.
7. Additional weightage up to 10% can be given for loss of sensation in each extremity but the total physical
impairment should not exceed 100%.
8. Neurological conditions which are reversible and without sequelae are not certifiable. Onl y neurological
conditions which are permanent are certifiable. If need be, in specific cases, are evaluation of disability can
be done after a period of one year.
9. The disability certificate should mention name of the Chronic Neurological Condition. (Clinic al
Diagnosis/Name of the disease, the nature, and the extent of disability as far as possible).
10. Permanent disability certificate can be issued in a few irreversible/progressive cases, if required for certain
specific needs/requirements by the person with d isability such as on directions from a Court. If needed in
specific cases, a re -evaluation of disability may be required after a reasonable and specified period such as 5
years or more or as decided by the Specified Disability Experts in the designated Med ical Board or as
specified by Law.
11. . The disability certificate shall clearly mention the name of the Chronic Neurological Conditions
25.2 Chronic Neurological Diseases of CNS .
Definition: Any impairment in the neurological function lasting > 3 months.
The following diseases may be assessed under the category of “LOCOMOTOR DISABILITY”
Locomotor disorders resulting from the following
1. Ataxia
2. Cerebrovascular Accident (Stroke)
3. Chronic Movement disorders (Neuronal Brain Iron accumulation (NBIA), Parkinson’s Di sease, Wilson
Disease, Genetic Dystonias, Huntington’s chorea, Subacute Sclerosing Panencephalitis (SSPE), Multiple
system atrophy, Progressive supranuclearpalsy,Tourette’s syndrome
(Choreoathetosis/Tremors/Dystonias/Parkinsonism/Myoclonus/Tremors/Chronic Tics)
4. Hereditary & acquired neuropathy
5. Motor Neuron disease
6. Myopathy
Other disorders;
1. Neurodegenerative disorders
2 Relapsing Recurring demyelinating disorders (such as Multiple Sclerosis, Neuromyelitis optica spectrum
disorder, Myelin oligodendrocyte a ntibody disease).
3. Paraneoplastic Syndromes
4. Chronic Drug Refractory Epilepsy *
Note: All these disorders will be assessed based on the presence of locomotor disability as well as presence of other
clinical features in the form of spasticity, cognit ion (IQ/DQ), vision & hearing and cranial nerve involvement.
25.3 Basis of Assessment .
It is estimated by reference to the physical or mental capacity for performance of the necessary functions of a normal
life, which would be expected in a healthy person of the same age and sex. It should represent the extent to which the
impairment has reduced that functional capacity. It is determined solely on general functional capacity. Consideration
should not be given to the member's capacity or incapacity to foll ow his own or any specific trade or occupation.
Assessment should be based on measurement of objective parameters which can be used to quantify the functional
loss.
For arriving at a proper assessment of impairment, it is necessary to elicit a conclusiv e history, carry out a thorough
clinical examination and all relevant laboratory and radiological investigations. It has to be determined whether the
impairment is temporary (2 years) or permanent and also the degree of impairment as it pertains to the fun ctional
capacity. In practice disability assessments for paediatric patients may be kept as temporary and re assessment may be
asked for within 3 -5 years. For adult patients’ temporary disability assessment may be given for disorders which are of
acquired nature and are expected to improve with therapy. For genetic disorders with relentless progression a
permanent disability may be offered.
The physical examination and laboratory tests must be relied upon more than ever to substantiate or disprove
symptoms and complaints. The evaluation of an impairment based on measurement of function is a sound procedure
by means of which a reliable medical opinion may be reached by reason or logic rather than by intuition, conjecture or
assumption.
The functional assess ment being parameter based and derived from guidelines of assessment based upon RPwD Act of
2016, GARP and other international disease specific guidelines will be provided by the concerned specialist.
25.4 The following chronic neurological diseases will be assessed under LOCOMOTOR DISABILITY.
25.4.1. Stroke
Stroke leads to multiple levels of neural axis being involved and contributing to impairment - ranging from
speech/language, cranial nerve, motor, sensory, locomotor and cerebellar dysfunction. The tot al functional impairment
is assessed as per RPwD act of 2016.The modified Rankin Scale (mRS ) is a commonly used scale for measuring the
degree of impairment or dependence in the daily activities of people who have suffered a stroke or other causes of
neuro logical impairment (Para 11.2 refers)
Apart from mRS which chiefly reflects the impairment due to motor functions, additional impairment caused due to
certain disabling deficits like visual or sectoral losses, aphasia or dysarthria etc. may be calculated f rom the relevant
sections and a composite impairment be arrived at (not exceeding 100%).
25.4.2. Chronic Progressive Ataxia (Sensory or Cerebellar)
Severity of Ataxia Physical Impairment
Score 0 -10Mild (Detected on examination) 25%
Score 11 -20Moderate 50%
Score 21 -30Severe 75%
Score 31 -40Very Severe 100%
For a very objective assessment Scale for the assessment and rating of ataxia (SARA) may be used. (Appendix -
XIV). Mean values from each one of the eight items are summed to obtain the total score. The tota l scores range from
0 (no ataxia) to 40 (severe ataxia).
**NOTE: SARA scores in children less than 8 years to be interpreted with caution (Only to be given after the
age of 8 years).
There is no percentage scoring available as per SARA score. Disability pe rcentage as per the scores is to
facilitate objective and uniform calculation.
25.4.3. Locomotor disorders resulting from movements disorders due to chronic neurologic diseases.
The following movement disorders should be assessed in patients with Chronic Movemen t disorders like Neuronal
Brain Iron Accumulation, Wilson disease, Huntington’s chorea, Genetic Dystonia etc.
Assessment of dystonia requires objective scoring.
Severity of Dystonia Physical impairment
Mild (present occasionally) 25%
Moderate (present most time of the day) 50%
Severe (present continually) 75%
25.4.4. Chorea: In the absence of a standardised universally acceptable method with respect to chorea related
disability, the following may be adapted for calculating permanent physical impairment.
Seve rity of Chorea Physical impairment
Mild Individual can use the involved extremity for activities of daily living
(ADL) involving gross movements but has mild difficulty in fine movements Non dominant limb -20%
Dominant limb -30%
Moderate Individual can use the involved extremity for activities of daily
living (ADL) with mild difficulty involving gross movements but has
moderate difficulty in fine movements Non dominant limb -30%
Dominant limb -40%
Severe Individual requires assistance in the involved extrem ity for activities
of daily living (ADL) with severe difficulty involving gross movements and
has severe difficulty in fine movements Non dominant limb -50%
Dominant limb -60%
25.4.5. Parkinsonism -
Definition “Parkinson's disease " means a progressive disease of the nervous system marked by tremor,
muscular rigidity, and slow, imprecise movement, chiefly affecting middle -aged and elderly people
associated with degeneration of the basal ganglia of the brain and a deficiency of the neurotransmitter
dopamine.
For asses sment of Parkinson’s disease (PD) the degree of impairment may be calculated from modified
Hoehn and Yar scale which grades the degree of functional impairment in case of PD .(Appendix -XV)
Stage Modified Hoehn and Yahr Scale Physical
Impairment
1 Unilater al involvement only 10%
1.5 Unilateral and axial involvement 20%
2 Bilateral involvement without impairment of balance 30%
2.5 Mild bilateral disease with recovery on pull test 40%
3 Mild to moderate bilateral disease; some postural instability; physic ally
independent 50%
4 Severe impairment ; still able to walk or stand unassisted 75%
5 Wheelchair bound or bedridden unless aided 100%
25.4.6. For Motor Neuron Disease like Amyotrophic lateral sclerosis: Functional rating scale for ALS
(Appendix -XVI) may be app lied as
Functional score Percentage of physical impairment
0-15 Severe 80 -100%
16-30 Moderate 60 -79%
29-40 Mild 40 -59%
40-48 Very mild<40%
25.4.7. For Neuropathy & Myopathy the following assessment may be used
Functional ability Percentage of physical
impairm ent
No significant impairment
Able to carry out all usual activities, despite some symptoms <40%
Mild impairment 40-50%
Able to look after own affairs without assistance, but unable to carry out all
usual activities
Moderate Impairment
Requires help but able to walk unassisted 51-60%
Severe impairment
Requires constant nursing care including use of assisted respiratory devices and
is bed ridden >80%
25.4.8. Bladder dysfunction may be assessed under the broad heading of Chronic Neurological Disease
Extent/Natu re of Bladder Function Deficit Percentage of physical impairment
Mild (Hesitancy, Frequency) * 20%
Moderate (Precipitancy)* 30%
Severe (occasional but recurrent incontinence)* 40%
Very severe (Retention/Total incontinence)* 50%
*Definitions of bladder dysfunction
Terms Definitions
Frequency Increased frequency is defined as those children who void 8 per day
Decreased frequency is defined as those children who void 3 per day
Urgency Sudden and unexpected experience of an immediate and compelling need to void. This
term is not applicable before the attainment of bladder control
Hesitancy Difficulty in initiating voiding when the child is ready to void
Precipitancy Also known as urinary incontinence.
Defined as involuntary leakage of urine
25.4.9. Scorin g method for disability in epilepsy
Severity of disability Numbers of convulsion Disability percentage
Mild One convulsion only Nil
Moderate 1-5/months 25
Severe 6-10/months 50
Very severe >10/months 75
25.4.10. Cognitive dysfunction - In children assessment o f cognition will be by an IQ score assessed on standard
scores by the Clinical Psychologist.
25.4.11. Dementia: The percentage disability for dementia is to be assessed as per IDEAS scale.
25.5. Multiple sclerosis " means an inflammatory, nervous system disease in which the myelin sheaths around the
axons of nerve cells of the brain and spinal cord are damaged, leading to demyelination and affecting the ability
of nerve cells in the brain and spinal cord to communicate with each other.
25.6. The impairment caused due to chroni c neurological conditions including Multiple Sclerosis are multi -
dimensional involving manifestation in muscular skeleton system, dementia,and also psycho -social behaviour.
Therefore, holistic multi -axial assessment is required as follows -
i The impairm ent in Musculo -skeletal system on account of these conditions shall be assessed in terms
of guidelines relating to assessment of locomotor impairment due to chronic neurological conditions as
in Locomotor Disability assessment as mentioned in the Section I
ii. Visual impairment assessment as mentioned in the Section II
iii. Hearing impairment assessment as mentioned in Section III A
iv. Cranial Nerve Involvement (Other than Vision & hearing
Type of Cranial Nerve Degree of Impairment
Isolated Motor Crani al Nerve 20% for each nerve
Isolated Sensory Cranial Nerve 10% for each nerve
v. Speech and Language assessment disability as mentioned in Section IIIB
vi. Intellectual Disability assessment as mentioned in Section IV
vii. psychosocial disability (mental illness) assessment as in Sectio V
Comprehensive impairment on account of all these conditions shall then be calculated by using the formula:
where
“x” is the composite percentage due to different disabling conditions accompanying Parkins on’s
disease/Multiple Sclerosis/Other chronic neurological conditions.
“a” is the percentage disability with higher score and
“b” is the percentage disability with lower score.
However, the maximum total percentage of multiple disabilities shall not exce ed 100%.
25.7 Medical Authority*:
The Medical Superintendent or Chief Medical Officer or Civil Surgeon or any other equivalent authority as notified
by the State Government shall be the head of the certification authority with the following two other me mbers:
a. Paediatrician/ Paediatric Neurologist for patients aged ≤18 yrs; Physician (Medicinespecialist)/ Neurologist for
patients aged >18 yrs
b. Specialist in Physical Medicine and Rehabilitation (PMR) or in case of non -availability of PMR Specialist, a
Spec ialist in Orthopaedics, for certifying locomotor disability component.
c. Psychiatrist for mental illness due to chronic neurological conditions
d. Trained psychologist (RCI certified clinical or rehabilitation)
e. A and B are mandatory and C and D will be coopt ed as the case may demand
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified ) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
Diseases covered:
A. Hemophilia
B. Thalassemia
C. Sickle Cell Disorders
Background
The inherited blood disorders at present covered by the RPwD Act, 2016 include severe Hemophilia A or B;
Thalassemia major, and Homozygous sickle cell disease . All of these lead to serious and permanent health
problems that are progressive over the person's lifetime. Th e persons with these disorders have a permanent disability
that can lead to adverse complications and are progressive. These persons require lifelong treatment to survive and VII. DISABILITY CAUSED DUE TO BLOOD DISORDERS x
manage their disease. With good treatment, some improvement in their symptom burd en will happen, but even with
good treatment complications because of their disease or their treatment will still occur. They require regular checkups
and it adversely affects their educational pursuits and employment. They need family support to avail the essential
treatment on a regular basis. Even with the standard of care treatment available in India, all persons with blood
disorders will experience limitations because of the disease, suffer the risk of complications, and reduced life
expectancy.
Hence benchmark disability of 40% is assigned to the patients fulfilling the diagnostic criteria of severe hemophilia,
thalassemia major, homozygous sickle cell disease and severe forms of compound heterozygous sickle cell syndromes
(sickle -beta Thalassemia and sickle -Hb D). The terminology Transfusion dependent thalassemia (TDT) and non -
transfusion dependent thalassemia (NTDT) is currently being used by most haematologists. All the disability are not
related to transfusion alone and these terms may not be used by some not familiar with this terminology, hence we
kept older terminology as well.
The disability is deemed to be permanent and hence, a certificate once issued should be valid till a reassessment is
requested by the patient or medical authority, which w ill be necessitated when the patient receives a curative treatment
like gene therapy, gene editing, or Hematopoietic stem cell transplant or when new novel drugs become available. All
diagnosis reports should ideally be from a government laboratory, or a s tandard laboratory; following these guidelines
will avoid discrepancy. If serious complications are present, or found on the disability assessment, then such persons
should be referred for appropriate therapy to control these problems and prevent further p rogression.
Individuals with blood disorder -related disabilities will be eligible for support mandated for individuals with high
dependency needs if they meet the existing criteria for high dependency person. Person with blood disorder related
disability having high support needs means a person with Benchmark Disability who needs intense support - physical,
psychological or otherwise, to carry out activities of daily living, access facilities/services, and to take decisions.
SECTION A: HEMOPHILIA
26.1 DISA BILITY ASSESSMENT AND CERTIFICATION GUIDELINES FOR HEMOPHILIA
Hemophilia A and B are hereditary hemorrhagic disorders characterized by deficiency or dysfunction of coagulation
protein factors VIII and IX, respectively. Recurrent joint and muscle bleeds occ ur and this leads to severe and
progressive musculoskeletal damage. Existing treatment relies on replacement therapy with clotting factors, either at
the time of bleeding (i.e., on demand) or as part of a prophylactic schedule. New non - factor agents and e xtended half -
life clotting factors are developed but not frequently used in the present date due to costs and availability. Regular use
of these products can help prevent injury and reduce disability. Patient with baseline clotting factor levels of less t han
2 % are associated with major and even life - threatening bleeds.
All hemophilia patients with less than 5 percent factor levels should be provided benchmark disability of 40%. For the
purpose of disability certification, criteria include a diagnosed cas e of HEMOPHILIA, with history of two or more
bleeds in the MAJOR JOINTS* OR one episode of INTRACRANIAL BLEED OR one episode of MUSCLE BLEED
and clotting factor VIII or IX level less than 5% is considered to have benchmark disability of 40 %.
26.2 What is HEMOPHILIA?
“Hemophilia” is an x linked inherited bleeding disorder. The disease is characterized by impairment of the normal
clotting ability of blood so that even a minor injury or even a tooth extraction may result in fatal bleeding. Patients
with sev ere hemophilia can even bleed spontaneously without any trauma. The disease is seen in males and rarely
in females.
Hemophilia is an inherited bleeding disorder with an X -linked recessive inheritance in 2/3 of families and new
spontaneous mutation seen in 1/3 of cases.
Factor VIII deficiency causes Hemophilia A and the deficiency of factor IX leads to Hemophilia B.
The severity of the deficiency leads to the bleeding phenotype.
Patients with less than 5 percent of either Factor VIII or IX have spontaneous bleeding episodes into the joints
and muscles, these lead to deformity and disability. These patients can even have life - threatening bleeds into the
brain or neck. Rarely mucosal bleeds like gastro -intestinal, oral, urinary tract etc.
26.3. Type of cert ificate
● Permanent certificate to be issued to all Hemophilia disease patients who fit the above criteria for
certification.
● The disease is permanent and progressive in nature.
● With respect to permanent disabilities, the reassessment, if requested by PwD s hall be considered after
five years if progression is noted.
● The individual would no longer be eligible for disability certificate post successful treatment with gene
therapy/ gene editing (whenever applicable).
26.4. Investigations for the basis of diagn osis of HEMOPHILIA and supporting documentation of need for
treatment Confirmatory Test and documentation: (See checklist at end of document)
1) A prolonged APTT report with factor assay. This is essential to document the deficiency of Factor VIII or
Facto r IX; and the degree of deficiency is required for eligibility criteria to be met under this disability heading.
If no reports are available then after a suitable washout period a repeat recent test report from an approved
standard laboratory will be requ ired to give a disability certificate
2) Documentation of treatment for hemophilia with a clotting factor or other available treatment, or physiotherapy
records or documentation of bleeds and radiology records demonstrating joint bleeds or damage.
3. Facto r VIII or IX level report
Documented evidence of History of bleeding due to clotting factor deficiency -
Major joints (ankle, knee, hip, elbow and shoulder joints)
Muscle bleeds, intracranial bleeds, bleeding during injury or surgery
Table 1 Disability s core assignment to patients with hemophilia (Blood disorder)
Disability
Score (%) Measured
Factor VIII or
IX level Clinical Criteria$
Select
only one 1. 1 5 5-50% (factor
VIII or IX) History of significant bleeding
during injury or surgery BUT no
defor mity and no severe chronic
pain# due to the disease
2. 2 20 5-50% (factor
VIII or IX) History of significant bleeding
during and injury or surgery AND
deformity OR severe chronic pain#
due to the disease
3. 40 <5%
(factor VIII or
IX) Hemophilia +
Document ation of two or more
bleeds in any MAJOR JOINT* or
muscles
4. 45 <5% (factor
VIII or IX)
Hemophilia = with deformity like
ONE MAJOR JOINT* AFFECTED
like Fixed Flexion Deformity OR
significant wasting of muscles
around the joint OR contracture OR
severe chronic pain#
5. 50 <5% Hemophilia =TWO MAJOR
JOINTS* AFFECTED like Fixed
Flexion Deformity OR significant
wasting of muscles around the joint
OR contracture OR severe chronic
pain#, OR gastro -intestinal bleeding
persistent
6. 55 <5% Hemophilia =THREE OR MORE
MAJOR JOINTS* AFFECTED like
Fixed Flexion Deformity
OR significant wasting of muscles
around the joint
OR contracture OR severe chronic
pain#
7. 60 <5% Hemophilia =Intracranial OR psoas
bleed causing neurological sequelae
leading to difficulty in usage of ONE
limb or presence of a Pseudotumor
8. 65 <5% Hemophilia =Intracranial OR psoas
bleed or pseudotumor causing
neurological sequelae leading to
difficulty in usage of TWO limbs
9. 70 <5% Hemophilia =Can't stand
independently BUT can walk, but
with the help of ONE crutch
10. 75 <5% Hemophilia =Can't stand
independently BUT can walk, but
with the help of TWO crutches
11. 80 <5% Hemophilia =Wheelchair bound due
to hip OR spine disability OR
paralysis of the lower limbs
12. 85 <5% Hemophilia =Wheelch air bound due
to hip OR spine disability OR
paralysis of the lower limbs AND
inability to use the dominant upper
limb
13. 90
<5% Hemophilia =Bed bound (confined
to bed) AND inability to sit up AND
inability to use the dominant upper
limb
but without vis ion and /or hearing
impairment
14. 95 <5% Hemophilia =Bed bound AND
inability to move all the four limbs
but without vision and /or hearing
impairment
15. 100 <5% Hemophilia = Bed bound AND
inability to move all the four limbs
with vision and /or hearin g
impairment
Select only one from boxes 1 to 15
Total score =
[May add additional score from 16 -18. If additional problems present. add scores given
below]
If transfusion -transmitted infection (TTI) is present the following
additional score w ill be added
(Laboratory tests from standard lab (HIV / HBsAg / HBV DNA/ HCV
RNA), all patients identified with TTI should be referred to higher
centers for treatment).
All TTI blood disorder patients must receive standard of care, ask a
hematologist / sp ecialist if in doubt about referral.
This recommendation is to ensure patients with treatable TTI get
appropriate treatment, this is not to discriminate, we want safety of all
patients, not merely a test for a score.
Select if
indicated HIV Infection (o n or off treatment) = 5
HBV Infection (on treatment) = 5
HCV infection (on treatment) = 5
None = 0
Select if
indicated
17 # Severe chronic pain denotes a score >100 in the pain scale which has
been mentioned in Appendix -XX
If the person with Hemophilia has end organ damage e.g., Liver due to
transfusion transmitted infections etc. then please refer to the table
scoring the liver damage (Appendix XVIII) and the percentage score
may be added to the score derived from this table
Add pain/ end organ score ( Appendix XVIII,XIX, XX) =
Not applicable =0
If
indicated
18 If the patient has additional other disabilities like neurologic , vision,
hearing -then the final disability percentage will be calculated as per
the formula mentioned in section VIII of this doc ument (Multiple
Disabilities) .
$ These percentages can in no way be simply added for final
certification e.g., do not add Hemophilia score + other disability
score (s)
If the person fulfils the criteria of multiple disability, then the
two with the higher disability percentage, will be considered for
certification. Multiple -
disability
board
assessment
Final Total score
@ The factor assay report should include the name and age of the person, the name and address of the laboratory, the
date of performin g the test and the full name and qualifications of the signatory. Tests from government hospital or
standard lab is recommended, NABL if possible is preferred. The report should be available at the time of certification
and a copy of the same should be ret ained for the records.
Patients should be referred for treatment of transfusion transmitted infections (TTI). If cured of Hepatitis B or C then
this score may be reversed.
Treatment referral /compliance indicated for all complications found to prevent pro gression of disease.
* Major Joints mean ankle, knee, hip, elbow and shoulder joints.
SECTION B: THALASSEMIA MAJOR/INTERMEDIA
27.1. DISABILITY ASSESSMENT AND CERTIFICATION GUIDELINES FORTHALASSEMIA
MAJOR/INTERMEDIA
“Thalassemia” is a group of inherited dis orders characterized by reduced or absent hemoglobin. It is a hereditary
hemolyticanemia resulting from a mutation in the hemoglobin genes. Beta -Thalassemia major patients have decreased
or no production of beta -globin chains, resulting in severe life -threatening anemia, affecting multiple organs. and is
associated with considerable morbidity and mortality. Thalassemia is genotypically divided into Thalassemia Major
(TM), Thalassemia Intermedia (TI) and Thalassemia Minor or Trait /carrier according to seve rity. Thalassemia Major
(TM) and the severe form of Thalassemia Intermedia (TI) constitute the disease’s major burden as both of these
conditions need regular treatment and monitoring.
Currently, based on their clinical severity and transfusion requiremen t, these thalassemia syndromes can be classified
phenotypically into two main groups; 1. Transfusion -Dependent Thalassemia (TDTs) and 2. Non -Transfusion -
Dependent Thalassemia (NTDTs). The persons with TDTs require regular blood transfusion to survive and w ithout
adequate transfusion support, they would suffer several complications and a short life span. This category includes
patients with β thalassemia major, and some patients of Thalassemia intermedia.
For purpose of disability certification, the patients of Thalassemia major and intermedia qualify for
benchmark disability of 40 %.
Thalassemia minor or trait is a carrier status, such persons have a normal life. Like the beta thalassemia trait or
carriers, many persons carry recessive genetic mutations for ma ny other diseases but do not manifest the disease,
hence they do not suffer from a disabling condition. Genetic counselling is helpful to reduce the incidence of
recessively inherited conditions.
Knowing your family history and being aware of the patient’ s mutation status can help prevent the births of children
with inherited recessive disorders like thalassemia major. If a family member has thalassemia, then cascade screening
of relatives is recommended. Being aware of thalassemia carrier status should be encouraged before marriage or at
least before planning pregnancy. The antenatal testing of both mother and father should be done, this is an important
public health step for prevention of the thalassemia disease states (TM and TI).
Thalassemia major and s ome severe thalassemia intermedia patients are offered matched sibling donor bone marrow
transplant also called Hematopoietic stem cell transplant or peripheral blood transplant from a healthy donor. This
replaces the blood forming cells of the body and cu res the disease. Now curative treatments like gene therapy and
gene editing by various methods are also approved in some countries and may soon be available to Indian patients.
When successful curative therapy by any of these or future methods are performe d then the disability certification and
scoring will not be applicable to that patient.
Rarely the procedure of bone marrow transplant is not curative or the patient may suffer from severe graft versus host
disease with organ dysfunction and residual disa bility or the patient suffers from loss of graft also called rejection and
continues to need blood transfusions. Then functional disability scoring will be performed using the same scale as for
initial disease.
A number of clinical complications commonly a ssociated with thalassemia intermedia are uncommon in thalassemia
major, including extramedullary hematopoiesis, leg ulcers, and thrombophilia (blood clots). This affects their quality
of life and hinders their full and effective participation in society.
Thalassemia major
27.2. Beta Thalassemia major is the most severe form of “thalassemia” disorders. Thalassemia major is an inherited disorder
characterized by reduced or absent amounts of beta globin production, which is an essential part of hemoglobin
It is characterized by severe anaemia requiring regular transfusions to prevent death. The blood transfusions start in infanc y
and are required life - long at an interval of 2 -3 weeks. Severe organ dysfunction occurs as a consequence to severe iron
overloa d/ transfusion dependent thalassemia These persons require lifelong supportive care and medical monitoring.
27.3. Disability score 40 %
27.4. Type of certificate
● Certificate with permanent validity to be issued to all transfusion dependent Thalassemia m ajor patients.
● Additional scores given if organ involvement or other parameters leading to disability (see Table 2 a).
● The disease is permanent and progressive in nature
● With respect to permanent disabilities, the reassessment, if requested by PwD shall be considered after five years if
progression is noted.
● The individual would no longer be eligible for disability certificate post successful treatment with gene therapy/
gene editing (whenever applicable).
27.5. Investigation basis of diagnosis of Thalass emia and supporting documentation of the need for treatment
Confirmatory Test and documentation :(See checklist at end of document)
1) Complete Blood Counts (CBC) with HPLC test of the child (pre -transfusion) or HPLC of parents showing thalassemia
carrier s tatus. Or molecular mutation test reports if patient is on regular transfusion and no pre transfusion HPLC report and
parents not available or if one parent has a silent mutation.
2. Documentation of Regular blood transfusion for Thalassemia major from tr eating canter (Government or Non -
Government)
and supportive records of other medications e.g., iron chelation medicines, or blood reports serum ferritin, LFT, etc.
Overview of Thalassemia intermedia / non transfusion dependent thalassemia (beta thalasse mia intermedia): (blood
disorder)
Thalassemia Intermedia /NTDT
27.6. What is Thalassemia intermedia?
A thalassemia syndrome is characterized by mild to moderate anemia; relative independence from transfusions; prominent
splenomegaly and bone deformities; variable degrees of iron overload depending on the severity of anemia and transfusion
requirement.
The clinical severity may range from almost asymptomatic to similar to thalassemia major -like phenotype
27.7. Disability 40%
27.8. Type of certificate
Thalassemia intermedia encompasses a wide clinical spectrum of beta -thalassemia phenotypes. Some thalassemia intermedia
patients are almost asymptomatic until they develop complications, whereas others are symptomatic from as young as 2 years
of age. A numbe r of clinical complications commonly associated with thalassemia intermedia are rarely seen in thalassemia
major, including extramedullary hematopoiesis, leg ulcers, and thrombophilia. Additional scores will be given in case of
organ involvement (secondary to iron overload related complications or other disease related sequelae (see table 2 (c).
The disease may be progressive in nature and requires regular health check -ups
Certification to be reviewed after 5 years if progression is observed by family membe rs or doctor
Persons can be reassessed on request of patient or family or doctor’s advice; or when the individual will no longer be eligib le
for disability certificate post successful bone marrow transplant or post Gene Therapy or gene editing (whenever av ailable).
New drugs that reduce need for transfusions will also impact on disability and some patients may have a reduction or no
further need of blood transfusion.
27.9. Investigation basis of diagnosis of Thalassemia intermediaandsupporting documentat ion of need for treatment
Confirmatory test and documentation
1. HPLC of the patient (pretransfusion or after a gap of 3 months from last transfusion) and HPLC of parents, is needed. If
neither unavailable then molecular mutation tests are required.
2. Do cumentation for chronic anemia, or blood transfusion, and/ or regular healthcare visits for a hydroxyurea or other
approved treatment. Documents include daycare /thalassemia clinic/hospital records/ patient diary
and supported any blood test reports e.g., like CBC, serum ferritin, LFT etc.
3. Supportive but not necessary - documentation of thrombosis or other complications
Table 2 Disability score assignment for organ involvement in patients suffering from thalassemia major TDT /
Thalassemiaintermedia NTDT (Blood disorder)
ORGAN INVOLVEMENT (# select organ involvement with documentation or physical assessment
as given in appendix)
Disability
score (%)
Select ONLY one that applies - (see diagnostic and documentation cri teria 2 a) and 2 b
Thalassemia intermedia on regular 2 –3-week blood transfusions = 40%
(needs supporting documentation as per thalassemia major)
Non-Transfusion dependent thalassemia (NTDT) / Thalassemia intermedia = 30%
Frequency of transfus ion (daycare/clinic/hospital or blood bank records of at least 2 years
documentation)
Less than once
a month /
infrequent
transfusion Once a month Twice a month > 3 per month
or 45 ml/kg/month for
pediatric patients
0 3 5 8
3 Endocrine Dysfu nction (requires tests reports)
Diabetes
Mellitus Thyroid
Dysfunction Parathyroid
Dysfunction Growth
abnormality Gonada
l
dysfunc
tion Osteo
por-
osis
2 2
2 2 2 3
4 Transfusion associated infections # (HIV / HBsAg/ HBV DNA/ HCV RNA)
(Hospital Do cumentation of HIV, Hep B infection or Hep C infection. All patients with TTI should be
referred for treatment).
HIV Infection
(On or off
treatment) HBV Infection
(on treatment) HCV infection (on
treatment)
Yes No Yes No Yes No
5 0 5 0 5 0
5 *Cardiopulmonary Dysfunction and/ or fatigue (check hemoglobin should be above 9g/dl in transfusion
dependent patients or at the steady state (2 measurements of haemoglobin 3 months apart) in NTDT) -
AppensixXVII
Asymptomatic NYHA Class 1 NYHA Class 2 NYHA Class 3 NYHA Class 4
0 Yes No Yes No Yes No Yes No
1 0 3 0 5 0 8 0
6 Hepatobiliary (see Appendix - XVIII for grading)
CTP
< 5 points CTP Class A
(5-6 points) CTP Class B
(7-9 points) CTP Class C
(10-15 points)
0 Yes no Yes No Yes No
3 0 5 0 8 0
7. Kidney (see Appendix -XIX for grading)
eGFR > 90 eGFR 90 -45 eGFR 45 -15 eGFR less than 15
0 3 5 8
8 Pain
PDQ score
(Appendix -
XX)
No or minimal
pain
PDQ Score
(0-10) Mild pain
PDQ Score (11 -
70) Moderate PDQ
Score (71 -100)
Severe
PDQ Score (101 -
130) Extre
me
PDQ
Score
(131-
150)
Yes No Yes No Yes No Yes No Yes
No
0 0 2 0 3 0 5 0 8
Total score 1 to 8 =
If criteria forother disabilityfulfilled, then assessment as per other disability g uidelines to be performed
and patient assessed by multi -disability board (see section VIII). Do not merely add the scores.
9 Neurological
Score as per the neurological disability guideline
Or not applicable =0 Multiple
disability
board
10 Locomoto r
Score as per the locomotor disability guideline
Or not applicable =0 Multiple
disability
board
11 Other disability - Vision impairment, Hearing impairment, Growth failure
Score as per the locomotor disability guideline
Or not applicable =0 Multiple
disability
board
Total Final score
(Criteria for organ involvement (maximum additional score for any single organ/system involvement will be 8).
The cumulative score for organ involvement should be added as a percentage to the baseline 40 perc ent to calculate
the percentage of disability.
*Cardiac function should be assessed when the patient is hemodynamically stable, and dysfunction is not due to acute
anaemia
#All patients with TTI or other complications should be referred for appropriate tre atment. Hepatitis B and C therapy
is available and persons with positive tests should be referred to government centers for therapy, support for therapy is
available, these are curable conditions, prompt treatment can prevent further sequala and complicati ons.
If Neurologic, vision, hearing, short stature – we need to use the formula for calculation provided in section VIII for
multiple disability calculation. The patient needs review in multiple -disability board.
PS: Major Investigations (T2*MRI, DEXA sca n, 2D -ECHO,) are optional, but can be supportive if done. These
investigations if submitted should be done in the previous 2 years for validity for certification. Patients with cardiac,
pulmonary, hepatic or other complications should be referred for appro priate medical intervention. Scoring is to be
done with standard medical treatment, patients not receiving medical care should be advised to take medical treatment
before certification wherever possible.
A multiple disability board will be required if sco ring for the following organ/system is being given
i. Vision impairment
ii. Hearing impairment
iii. Growth failure
iv. Locomotor disability
v. Neurological involvement
SECTION C:
28. DISABILITY ASSESSMENT AND CERTIFICATION GUIDELINES FOR SICKLE CELL DISEASE
(SCD) SYNDROMES
Sickle cell anaemia is a multisystem disorder that is caused by a single gene mutation. Nearly every organ in the body
can be affected. Characterized by the presence of abnormal erythrocytes damaged by HbS, this variant of normal adult
hemoglobin (HbA) is i nherited either from both parents (homozygosity for the HbS gene=HbSS), also sometimes
termed homozygous sickle cell disease. Some patients can have symptoms even if they have co -inheritance of HbS
from one parent and another hemoglobin variant, such as β -thalassemia or rarely in India with hemoglobin D (HbD)
from the other parent. (These disorders are called compound heterozygote states example sickle - beta thalassemia
fer from high symptom burden
and complications.
People who inherit one sickle cell gene and one normal gene have sickle cell trait (SCT) and are called sickle cell
carriers. People with SCT usually do not have any of the symptoms of sickle cell disease (SC D), but they can pass the
trait on to their children. The sickle cell trait in the present guideline will get a score of 5 %.
Although early diagnosis, penicillin prophylaxis, blood transfusion, transcranial Doppler imaging, hydroxyurea, and
hematopoietic stem -cell transplantation can dramatically improve survival and quality of life for patients with sickle
cell disease, they continue to require lifelong care and support.
For the purpose of disability certification, the patients with sickle cell anemia /Ho mozygous sickle cell disease
(HbSS)will qualify for a benchmark disability of 40%. Also, the patients who suffer from sickle -beta thalassemia
documented clinically severe phenotype.
Sickle cell trait persons are a carrier sta tus, such persons have a normal life, many persons carry recessive genetic
mutations for many other diseases but do not manifest the disease hence they do not suffer from a disabling condition.
Knowing the family history, and being aware of the patient’s m utation status can help prevent the births of children
with inherited recessive disorders like sickle cell anemia and sickle cell compound heterozygote states like sickle beta
thalassemia and sickle HbD disease. Testing and being aware of sickle cell carri er status should be encouraged and
antenatal testing of both mother and father should be done.
Bone marrow transplant also called hematopoietic stem cell transplant (HSCT) can be recommended as per standard
guidelines for sickle cell patients with severe d isease and complications who do not respond to standard available
therapy even with good compliance and adequate doses. This procedure should be performed in centers with
experience in transplantation. In rare cases, the post bone marrow transplant is not curative and the patient may suffer
from graft versus host disease with organ dysfunction and residual disability or the patient suffers from loss of graft
and needs medicines to prevent crises or blood transfusions. Then functional disability scoring will be performed
using the same scale as for sickle cell disease.
The newer curative therapies are on the horizon such as gene therapy, gene editing and alternate donor hematopoietic
stem cell transplant as well as possibility of new novel medicines that alt er the disease. Once these are available and
applied, then those who are cured of their disease or disability, will not be entitled to disability certificate.
An overview of sickle cell disease (blood disorder) disability information .
28.1. Type of disab ility
Sickle cell disease syndromes
(Homozygous sickle cell disease, sickle beta thalassemia and sickle with HbD disease)
28.2 What is Sickle cell disease?
“Sickle cell” is a hemolytic disorder characterised by chronic anemia, painful events, and vario us complications due to
associated tissue and organ damage; “hemolytic” refers to the destruction of the cell membrane of red blood cells resulting i n
the release of hemoglobin.
28.3 Sickle cell disease is caused by a variant hemoglobin disorder. The abno rmal hemoglobin results in hemolysis, sickling
of red blood cells that lead to pain, and organ dysfunction and increased risk of infections. These patients have poor qualit y
of life due to crises and organ damage.
The patients inherit this disorder which i s an autosomal recessive disease. The parents of these patients may be sickling
carriers or trait, some siblings may also be carriers and they also do not need any treatment.
Some patients may need blood transfusion support, but this is required in only i n some patients, patients can suffer Vaso -
occlusive crises even if no blood transfusions are needed.
28.4. Disability score 40%.
28.5. Type of certificate
● A certificate with permanent validity shall be issued to all Sickle cell disease patients
● The disease is permanent and progressive in nature
● With respect to permanent disabilities, the reassessment, if requested by PwD shall be considered after five years if
progression is noted.
● The individual would no longer be eligible for disability certificat e post successful treatment with gene therapy/
gene editing (whenever applicable).
28.6. Investigation basis of diagnosis of SCD and supporting documentation of need for treatment
Confirmatory Test and documentation :
1. HPLC test of the patient (not tran sfused in last 3 months) or both parents HPLC showing HbS carrier status in both
parents and symptoms in the patient.
2. Documentation of treatment for crises, and hospitalization for complications.
Or documentation of regular treatment with hydroxyurea o r other approved treatment etc. or records of blood transfusions or
complications like Vaso -occlusive crises (VOC) from the sickle cell treating centre/ daycare/hospital (government or non -
Government)
(If HPLC not available of patient or even parents -then documented government recognized tests like hemoglobin
electrophoresis or government recognized point of care test &the presence of medical reports or records of treatment for
sickle cell disease and / or physical evidence of sickle cell disease complicat ions or test reports of current SCD related
complications)
Overview of sickle cell disease syndromes
28.7. What is Compound heterozygous Sickle cell disease?
Hemoglobinopathy in which the sickle mutation is inherited in combination with another globin gene
mutation (affecting alpha globin, beta globin, or gamma globin). These syndromes may have different clinical severity
compared with homozygous sickle mutation (HbSS).
28.8. Disability score
Compound heterozygous Sickle cell disease which has a severe phenotype – HbSβ and HbSD or HbSC
40 %
Other Compound heterozygous Sickle cell disease 30 %
28.9. Type of certificate
A certificate with permanent validity shall be issued to all who suffer from compound
Heterozygote states of HbSβ and HbSD, rarely see n in India.
The disease may be progressive and requires regular health check -ups
With respect to permanent disabilities, the reassessment, if requested by PwD shall be considered after five years if
progression is noted.
The individual would no longer be e ligible for disability certificate post successful treatment with gene therapy/ gene
editing (whenever applicable).
The individual would no longer be eligible for disability certificate post successful bone marrow transplant or post
Gene Therapy or Gene ed iting (whenever available).
28.10. Investigation for basis of diagnosis of SCD and supporting documentation of need for treatment or presence of
complications
Confirmatory Test and documentation :
1. HPLC test of the patient (pre -transfusion or not transf used in last 3 months). If on regular transfusion support and no HPLC
tests are available then either the mutation test of patient or HPLC of both parents showing documented hemoglobinopathy or
variant haemoglobin. If neither available or possible then mut ation test will be needed.
2. Documentation of treatment for crises, and hospitalization for complications.
Or documentation of chronic anaemia or documented VOC with regular treatment with hydroxyurea or other treatment etc.
Or records of blood transfus ions from the sickle cell treating centre/ day care/hospital (government or non -government).
Or Documentation of sickle cell disease related complications physical and tests reports.
Patients require Hydroxyurea, folic acid, immunizations, and penicilli n prophylaxis during childhood. Good medical
care and monitoring reduce frequency of pain crises, and may decrease the complications or may delay the
development of complications. Some patients may require infrequent or even regular blood transfusions.
Hem atopoietic stem cell transplant (HSCT) also called bone marrow transplant is curative but is best for younger
children without organ compromise, but with the presence of complications that justify the risks associated with
HSCT.
Complications of the condi tioning medicines used for HSCT lead to infections in the peri -transplant period. The other
complications of transplant are graft versus host disease, veno -occlusive disease of the liver, and skin and immune
problems. Rarely secondary cancers can develop. Organ damage caused by the disease is usually not reversible by
HSCT. Adequate counselling for realistic outcome expectations is required .
Table 3 Disability score assignment for patients suffering from Sickle cell disease (Blood disorder)
Select ONE that applies – (see documentation table 3 a) and 3b) Disability
score (%)
1 Homozygous sickle cell disease (SCD)/ sickle cell anemia/ HbSS= 40%
Compound Sickle cell syndromes Sickle disease syndromes of either
Hb sickle beta -thalassemia OR Hb sickl e D= 40%
Other compound heterozygote sickle cell syndromes
=30%
2 Pain (chronic pain includes backpain, priapism, avascular necrosis (AVN), or any other sickle disease -
associated pain)
PDQ score
(Appendix -
XX)
No or
minimal
pain
PDQ
Score
(0-10) Mild pain
PDQ Score (11 -
70) Moderate PDQ
Score
(71-100)
Severe
PDQ Score
(101-130) Extreme
PDQ Score
(131-150)
0 2 3 5 8
3. Blood transfusion requirement (daycare/ clinic/hospital/blood bank records report at least 2 years
documentation and CBC more than 6 months apart)
More than 3 days of transfusion per year Or Alloimmunization
5 5
4 Endocrine Dysfunction
Diabetes
Mellitus Thyroid
Dysfunction Parathyroid
Dysfunction Growth
abnormality Gonadal
dysfunction Osteopo
rosis
2 2 2 2 2 3
5 Transfusion associated infections # (HIV/ HBsAg/ HBV DNA/ HCV RNA)
(Hospital Documentation of HIV, Hep B infection or Hep C infection or Treatment documentation)
All patients diagnosed with TTI shoul d be referred for treatment
HIV
Infection HBV Infection
(on therapy) HCV infection (on therapy)
5 5 5
6. *Cardiopulmonary Dysfunction and /or fatigue (checkhemoglobin is at steady state) – examine for cardiac
failure, cardiac hemosidero sis, pulmonary arterial Hypertension, chronic lung disease (see Appendix -
XVII for how to grade)
Asymptom
atic NYHA
Class 1 NYHA Class 2 NYHA Class 3 NYHA Class 4
0 1 3 5 8
7 Hepato -biliary dysfunction (see Appendix -XVIII for how to grade)
CTP
< 5 points CTP
Class A
(5-6
points) CTP Class B
(7-9 points) CTP Class C
(10-15 points)
0 3 5 8
9. Kidney dysfunction (see Appendix -XIX for how to grade)
eGFR > 90 eGFR
90-45 eGFR 45 -15 eGFR less than 15
0 3 5 8
Total score 1 -9
If mul tiple disability (see section VIII)does not only add score, use formula provided for calculation, if
several disability criteria fulfilled then the two disabilities with maximum scores used. Send patient to
multiple disability board for complete assessment .
10 Neurological complication
Physical assessment (Stroke, Neurocognitive impairment)
(Imaging with CT/MRI – supportive if available)
or cognitive impairment /MR scoring as per recent Gazette updated guidelines. Multiple
disability
board
Score as pe r the neurological disability guideline
Or
Not applicable=0
11 Locomotor (AVN, paralysis, osteomyelitis etc.) Multiple
disability
board Score as per the locomotor disability guideline
Or
Not applicable=0
12 Ophthalmological complication Multiple
disability
board Diminished
vision As per the visual disability assessment
Or
Not applicable=0
Total Final score
*Cardiac function should be assessed when the patient is hemodynamically stable, and dysfunction is not due to acute
anaemia
Criter ia for organ involvement (maximum additional score for any single organ/system involvement will be 8)
#All patients with TTI or other complications should be referred for appropriate treatment. Hepatitis B and C therapy
is available and persons with positi ve tests should be referred to government centers for curative therapy, support for
therapy is available.
If Neurologic, vision, hearing, short stature – we need to use formula for calculation provided in for multiple
disability calculation. The patient ne eds review in multiple -disability board. If multiple disabilities are present - then
the total is as per the formula given in.
29.1. Requirement for the multispecialty board if following organ/system involvement is assessed
1. Vision impairment
2. Growth failure
3. Locomotor disability
4. Neurological involvement cognitive impairment
5. Hearing impairment
29.2. Medical Authority*:
Certifying authority (from Government or others) for certification and evaluation of disability due to blood
disorder shall comprise of the fol lowing: -
(a) Chairperson -Chief District Medical Officer or the Chief Medical Officer or Medical Superintendent of the
hospital.
(b) Members -
i. Treating doctor Hematologist (adult or pediatric) or General Medicine or Paediatricianor General
physician or as the case may be and the availability of experts.
ii. PMR expert or Orthopaedic surgeon, if required.
iii. Other Specialists: In case of sequelae relating to visual abnormality, hearing problem, cerebral
dysfunction, etc. In case of limitation of availability of any expert, which ever additional experts are
available can be included.
iv. End organ damage (if doubt or difficulty in assessment) then only if needed additional specialist may be
included as per the discretion of chairperson. But undue delay or inconvenience to patient is to be
avoided.
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specif ied) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
A Benchmark disability of 40% is assigned to the patients fulfilling the diagnostic crit eria of severe hemophilia,
thalassemia major or intermedia, transfusion -dependent thalassemia intermedia, homozygous sickle cell disease, and
severe forms of compound heterozygous sickle cell syndromes (Sickle -Beta Thalassemia and Sickle -HbD). With
respect to permanent disabilities, the reassessment, if requested by PwD shall be considered after five years if
progression is noted (as per the format given below).
The individual would no longer be eligible for disability certificate post successful treatment with gene therapy/ gene
editing (whenever applicable).
Application for reassessment of disability
(To be submitted to the certifying authority which issued the existing certificate or the certifying authority at
the current place of residence of the appli cant with disability)
(1) Name : ________________ __________________ _________________ (as mentioned in the existing certificate
of disability)
(2) Father's Name : ___________________ Mother's Name: ________________
(3) Date of Birth : __________/______ ______/_____________ (Date) (Month) (Year)
(4) Sex: Male/Female/Transgender__________________
(5) Address:
(a) Permanent address :
(b) Current address, if the applicant has shifted outside the jurisdiction of the certifying authority of the existing
certificate of disability (Please enclose proof thereof (e.g. transfer of the parent/ legal guardian/ shifting of residence
(allotment of house/ rent agreement, any other relevant document) :
__________________ __________________ __________________
_________ ________________________________________________
(d) Contact details of the person with disability or legal guardian or the person who can be contacted when required :
Mob/telephone number :_______________Email Id, if available :___________
(6) Type of di sability :
(7) Percentage of disability :
(8) Name and address of the hospital/ certifying authority which issued the existing certificate of disability (enclose a
copy of the existing certificate of disability) :
(9) Reason for reassessment : (Please stri ke off the reasons that are not applicable)
(i) Validity of my existing certificate has expired on___________
(ii) Validity of my existing certificate will be expiring on _______________
(iii) My disability has worsened
(iv) My disability has improved
(v) I am no longer eligible for disability certificate post successful bone marrow transplant or post Gene
Therapy conducted on______________________(Please enclose the copy of the certificate/ record pertaining
to transplant/ gene therapy / gene editin g
duly signed by the treating doctor).
(10) Declaration:
I hereby declare that all particulars stated above are true to the best of my knowledge and belief, and no material
information has been concealed or misstated. I further state that if any inaccur acy is detected in the application at any
stage, I shall be liable to forfeiture of any benefits derived and other action as per law.
________________________
(signature or left thumb impression of the person with disability or of his/her legal guardian in case of persons with
multiple disabilities, etc)
Date : _________________
Place: __________________
Enclosures:
1. Copy of existing certificate of disability.
2. Copy of the certificate/ record pertaining to successful bone marrow transplant or Gene T herapy duly signed by the
treating doctor.
3. Proof of change of residence {Please see Sl. Number (5) (b)}. In case of an inmate of a residential institution for
persons with disabilities or destitute, etc., a certificate of residence from head of such ins titution be enclosed.
4. Two recent passport size photographs.
(For office use only)
Upon reassessment of the disability:
(i) A fresh certificate of disability with _________percentage of disability (mention type of disability) issued on
___________________ ____and the existing disability certificate
dated__________________________has been cancelled.
(ii) Issuance of fresh certificate of disability is not considered necessary.
Signature of issuing authority
Official Stamp
Date: ______________________
Place: ____ __________________
HEMOPHILIA
Checklist:
1. Factor VIII or IX level: (The factor assay report should include the person's name and age, the laboratory's
name and address, the date of performing the test, and the full name and qualifications of the signatory. The
report should be available at the time of certification and a copy of the same should be retained for the
records)
2. History of bleeding:
a. Major joints ( ankle, knee, hip, elbow, and shoulder joints)
b. Muscle bleeds
c. Intracranial bleeds
d. Bleeding during injur y or surgery
3. Joint Status:
a. Fixed Flexion Deformity
b. Significant wasting of muscles around the joint
c. Contracture
4. Severity of Chronic Pain
5. Ambulatory Status
a. Use of crutches
b. Use of Wheelchair
c. Bedbound
6. Neurological sequelae
7. Transfusion Transmitted Infections
8. Multiple disability board assessment for persons with additional disabilities as per guidelines -
Vision impairment
Hearing impairment
Neurological involvement
THALASSEMIA Disease states
Checklist:
1. Complete Blood Counts (CBC) with HPLC test of the child ( pretransfusion) or HPLC of both parents showing
thalassemia carrier in both parents or molecular test report. In case of thalassemia syndromes HPLC or molecular tests
of patient or if transfused of parents. ( The HPLC/molecular report should include the per son's name and age, the
laboratory's name and address, the date of performing the test, and the full name and qualifications of the signatory.
The report should be available at the time of certification and a copy of the same should be retained for the rec ords)
2. Documentation of Regular blood transfusion for Thalassemia major from the treating center (Government or Non -
Government), chelation records daycare, outpatient card/diary. In thalassemia intermedia documentation of
transfusions
3.Supportive record s of other medications e.g., iron chelation medicines, or blood reports serum ferritin, LFT, etc.
Imaging, investigations for complications, records of inpatient or outpatient visits and medication records.
4. Investigation to support Endocrine dysfunction - if any
5. For patients with liver dysfunction - Bilirubin, Albumin, and Prothrombin report (CTP calculation)
6. For patients with Kidney dysfunction - Serum creatinine report (EGFR calculation)
7. Investigation to support transfusion -transmitted infection (HIV, HBV, HCV)
7. NYHA questionnaire
8. PDQ questionnaire
9. Multiple disability board assessment for persons with additional disabilities as per guidelines -
Vision impairment
Hearing impairment
Growth failure
Locomotor disability
Neurological involvemen t
SICKLE CELL DISEASE
Checklist:
1. Complete Blood Counts HPLC test of the patient (not transfused in last 3 months) or both parents HPLC showing
HbS carrier status and symptoms in the patient for sickle homozygous. Or one parent who is sickle carrier and one
who is either beta thalassemia trait (carrier) or HbDcarrier. ( The HPLC/molecular report should include the person's
name and age, the laboratory's name and address, the date of performing the test, and the full name and qualifications
of the signator y. The report should be available at the time of certification and a copy of the same should be retained
for the records). Or government approved Hb electrophoresis/POC with supportive documentation of SCD
complications or healthcare visits for treatment.
2. Documentation of treatment for crises, and hospitalization for complications
Or documentation of regular treatment with hydroxyurea or other approved etc. or records of blood transfusions from
the sickle cell treating centre/ day -care/hospital (governme nt or non -Government)
3. Documentation for blood transfusion
4. Investigation to support -Endocrine dysfunction - if any
5. NYHA questionnaire (Appendix XVII)
6. For patients with liver dysfunction - Bilirubin, Albumin, and Prothrombin report (CTP calculati on) required if
claiming . (Appendix XVIII)
7. For patients with Kidney dysfunction - Serum creatinine report (EGFR calculation) will be required if claiming.
(Appendix XIX)
8. Investigation to support transfusion -transmitted infection - (HIV, HBV, HCV)
9. PD Q questionnaire (Appendix XX )
10. Multiple disability (see section VIII) board assessment for persons with additional disabilities as per guidelines -
Vision impairment
Hearing impairment
Growth failure
Locomotor disability
Neurological involvement, cogniti ve impairment
30.1. DEFINITION
Multiple Disabilities means a combination of two or more types of disabilities, namely
(i) Locomotor disability (due to any cause including orthopaedic, cardiac, respiratory, burn injuries including burn
injuries due to acid exposure/attack)
(ii) Visual impairment;
(iii) Hearing impairment;
(iv) Disability associated with blood related disorders.
(v) Developmental disorders (including Global Developmental Delay, Intellectual Disability, Specific Learning
Disability, Autis m Spectrum Disorder etc. VIII. MULTIPLE DISABILITIES
(vi) Mental illness
(vii) Chronic Neurological Disorders
ASSESSMENT
30.2. Guidelines for Assessment :
The guidelines used for individual disability shall be used for assessment of each specific disability of a person having
multipl e disability, in the first instance. Each disability will be evaluated and the degree of disability will be calculated by
the notified Specialists. Based on the score received for each disability, they will be graded from the most severe to the
least seve re. Only individual disability is more than or equal to 25% will be included for assessment of composite
disability due to multiple disabilities.
If disability due to a particular disability is given as range and not as a discrete number, then midpoint of the range will be
used while calculation of multiple disability. For example, if disability due to mental illness is determined to be moderate
i.e., 40 to 70 %, then for calculation of severity of multiple disability, mental disability of 55% will be used . Similarly, if
disability due to mental illness is determined to be severe i.e., 71 to 99%, then for calculation of severity of multiple
disability, mental disability of 85% will be used.
Subsequently, in order to arrive at the composite total percentage due to multiple disabilities, the following combining
formula shall be used
where
“x” is the composite total percentage due to multiple disabilities.
“a” is the percentage disability with higher score and
“b” is the percentage disability wit h lower score.
However, the composite total percentage due to multiple disabilities shall not exceed 100%.
Example 1: If the percentage of hearing disability is 40% and the percentage of visual disability is 30%, then by
applying the combining formula give n above, the total percentage of multiple disabilities due to hearing disability and
visual disability will be calculated as follows: -
If a person has more than two disabilities, the above formula will be successively applied beginning with the two
disabilities with the highest percentage scores and proceeding further by including the next lower percentage score in
the calculation.
For example, a person has 3 Disabilities. The percentage score for first disability is the highest equal to “a”; the scor e
for the second disability is equal to “b” (second highest); and score for third disability is equal to “c” the lowest score.
According to the above formula:
(score of disability 1 and 2 = x)
This(x) will become (a) for the purpose of calculation of composite disability due to the three disabilities which is y.
x
=58%
x
Such calculation will continue till the last disability (with severity score more than or equal to 25%) is covered. The
final figur e will be the composite disability due to all the multiple disabilities.
The maximum composite disability score is 100%.
Example 2: If the percentage of intellectual disability is 50%, percentage of hearing disability is 40% and the
percentage of visual d isability is 30%, percentage of locomotor disability is 10%, then by applying the combining
formula given above, the total percentage of multiple disabilities will be calculated as follows: -
Step 1: intellectual disability 50%, hearing disability 40%
Step 2: Composite of intellectual disability and hearing disability 70% plus visual disability 30%
Step 3: In case of persons having more than two disabilities, this formula will be applicable starting from disability
having the highest percentage a nd taking two disabilities at a time. For the third disability, the resultant of above
formula, as applied to the two higher % disabilities, will become the higher disability “x” in the above -mentioned
formula. Such calculation will continue till the last disability is covered subject to a maximum of 100%.
The certificate due to multiple disabilities will provide the composite disability due to all the multiple disabilities, as
above. Further, all the different multiple disabilities will be listed in the di sability certificate.
30.3 MEDICAL AUTHORITY*:
There shall be a standing medical board in all government institutions certifying for multiple disability. The standing
medical board will convene periodically depending on the applications received for asses sment of multiple
disabilities.
The standing medical board shall comprise of the following: -
(a) The Medical Superintendent or Chief Medical Officer or Civil Surgeon or Plastic Surgeon or any other
equivalent authority as notified by the State Government – Chairperson
(b) Specialists required for assessing the individual disabilities as per the requirement of respective guidelines for
Locomotor disability, Visual impairment, Hearing impairment, Disability associated with blood related disorders,
Developmen tal disorders, Mental illness and Chronic Neurological Disorders.
Note* - In view of shortage of the specialist doctors resulting in huge pendency in disability assessment, the
chairperson (Who compulsorily has to be a Government Doctor e.g. Chief Medical Officer or Civil Surgeon or as
specified) of the disability assessment board may, if required, include private medical practitioner(s) (duly qualified in
the respective medical domain) as a board member.
List of Appendices for Inclusion in the Guidelines for Purpose of Assessing the Extent of Specified Disability
in a Person included under the Rights of Persons with Disabilities Act, 2016 (49 of 2016)
Appendix No Subject If Free or Copy righted
I. Muscle Strength Grading (Medical Research Council - MRC
scale) Freely Available**
II. Form A Assessment Proforma for Upper Extremity Freely Available**
=79%
Form B Assessment Proforma for Lower Extremity
III. Average Normal Range of Motion (degrees) at Different Joints: Freely Available**
IV. Perceptual Speech Intelligibil ity Rating Scale (AYJNISHD,
2022) Freely Available**
V. Consensus Auditory Perceptual Evaluation of Voice (CAPE -V) Freely Available**
VI. Vineland Social Maturity Scale Copyrighted
VII. Malin’s Intelligence Scale for Indian Children (MISIC) Copyrighted
VIII. A.WIS C -IV Wechsler’s Scale for Children ……
B. Binet Kamat Test ( BKT)……………………..
C. NIEPID IQ TEST ……………………………. Copyrighted
Copyrighted
Freely Available**
IX. NIMHANS Index for SLD Copyrighted
X. Grade Level Assessment Device for Children with Learning
Problems in School - GLAD (NIEPID) Freely Available**
XI. AIIMS -Modified INCLEN Diagnostic Tool for ASD Freely Available**
XII. Indian Scale for Assessment of AUTISM Freely Available**
XIII. Indian Disability and Assessment Scale(IDEAS) Freely Available**
XIV. Scale for the Assessment and Rating of Ataxia (SARA) Freely Available**
XV. Modified Hoehn and Yahr Scale Freely Available**
XVI. ALS Functional Rating Scale Revised (ALS -FRS-R) Freely Available**
XVII. The New York Heart Association (NYHA) Functional
Classification Freely Ava ilable**
XVIII. CTP Calculation Freely Available**
XIX. EGFR Calculation Freely Available**
XX. Pain Disability Questionnaire (PDQ) Freely Available**
Note**: - The Latest versions of freely available tests should be used as updated from time to time.
Sub-committees for Review of Guidelines for Purpose of Assessing the
Extent of Specified Disability in a per son included under the Rights if
Persons with Disabilities Act, 2016 (49 of 2016)
Under the esteemed guidance of Dr. Atul Goel, DGHS, following members worked
for the revising of Assessment Guidelines for Disability -
I. For Overall Chairperson for All the Sub- Committee: Dr. Sunita Mondal, Dir & Prof,
Dept. of Physiology, LHMC & Associated Hospital
II. For Overall Member Secretary for All the Sub - Committee: Dr. Rupali Roy, Assistant
Director General, Dte.GHS
III. Members from Dte.GHS: Dr. Anita Bali Vohra, Deputy D irector General, Dte.GHS
Following sub -committees were constituted to revise the Assessment Guidelines for
Disability -
1. Sub-Committee on Mental Illness
S No Composition Committee Designation
1 Prof. Pankaj Verma
HoD, Psychiatry, SJH, Delhi Chairperson
2 Dr. Mina Chandra
HoD, Psychiatry, ABVIMS & RMLH Member
3 Dr. Smita Despande
Ex Psychiatrist RMLH, Advisor Member
4 Dr. Manushree Gupta
Associate Prof. SJH, Delhi Member
5 Ms. Pragati Pandey
Asst. Prof. NIMHR Member
6 Dr. Rohit Verma
Asst. Prof. Department of Psychiatry, AIIMS,
Delhi Member Secretary
2. Sub-Committee on Locomotor Disability
S No Composition Committee Designation
1 Dr Sanjay Wadhwa
Prof. & HoD, Dept. of PMR, AIIMS Chairperson
2 Dr. Ritu Mazumdar
HoD PMR, LHMC & KSCH Member
3 Dr. B.D. Athani
Ex Spl. DGHS, Advisor, Member
4 Dr. Satish Kumar
HoD Orthopedic, Dr. RMLH Member
5 Dr. Shishir Chandan
Prof. Neurology, SJH, Member
6 Dr. Desh Deepak
Consultant Respiratory Medicine Member
7 Dr. Ajay Raj Member
Prof. Cardiology, Dr. RMLH
8 Dr. Sameek Bhattacharya
Burn & Plastic, Dr RML Hospital Member
9 Shri T.D Dhariyal
Former Deputy Chief Commissioner, GoI and State
Commissioner for PwD, Delhi Member
10 Director
SVNIRTAR, Cuttack Member
11 Dr, Suman Badhal
Prof, PMR SJH, Member Secretary
3. Sub-Committee on Visual Impairment
SL.No.
Composition
Committee Designation
1 Dr. Ritu Arora
Dir. Prof. Ophthalmology Dean,
Maulana Azad Medical College, New Delhi Chairperson
2 Dr. Sarita Beri
HoD Ophthalmology, LHMC & Asso. Hospital Co-Chairperson
3 Dr. Radhika Tandon
Prof. Ophthalmology, AIIMS Member
4 Dr. Rajiv Garg
Ex DGHS, Adviser Member
Director
NIEPVD, Uttarakhand Member
6 Dr Anuj Mehta
Prof, Dept of Ophthalmology, Safdarjung Hospital Member Secretary
4. Sub-Committee on Hearing Impairment
S. No. Composition
Committee Designation
1 Dr. Arunbha Chakravrti
Director & Prof, Dept. of ENT, LHMC Chairperson
2 Dr. Isha Preet Tuli
Prof. ENT, VMMC & SJH Member
3 Director
AYJNISHD, Mumbai Member
4 Mr. Parbhakar Upadhyay
Audio Metrician, Dept. of ENT, LHMC Member Secretary
5. Sub-Committee on Developmental Disorder
S. No.
Composition
Committee Designation
1 Dr. Dr. Sheffali Gulati
Prof. Child Neurology Division, Department of Chairperson
Pediatrics, AIIMS, Delhi
2 Dr. Mina Chandra
HoD, Psychiatry, ABVIMS & RMLH Member
3 Dr. Paul Russell
Professor & lead Consultant, CMC Vellore,
Tamilnadu Member
4 Dr. Sharmila B. Mukharjee
Prof. Dept. of Pediatric, LHMC, Delhi Member
Director, NIEPID, Secunderabad, Telangana Member
6 Dr. Madhuri Kulkarni
Ex Head Dept. of Pediatrics, L.M.M. Medical
College, Maharashtra Member
7 Dr. Vishal Sondhi
Prof. Department of Pediatrics, AFMC, Pune Member Secretary
6. Sub-Committee on Blood Disorder
S. No. Composition
Committee Designation
1 Dr. Tulika Seth
Prof. Dept. of Hematology, AIIMS, Delhi Chairperson
2 Dr. Dipty Jain
Ex HoD, Dept of Pediatrics, GMC, Nagpur Member
3 Dr. Cecil Ross
Prof. of Medicine and Hematology, St. Johns
Medical College Hospital, Bangalore Member
4 Dr. Prantar Chakraborty
Consultant, Clinical Haematology, Vivekananda
Institute of Medical Sciences Member
5 Shri TD Dhariyal
Former Deputy Chief Commissioner, GoI and State
Commissioner for PwD, Delhi Member
6 Dr. Ritika Sud
Prof. Medicine LHMC, New Delhi Member
7 Ms. Shobha Tuli
President Thalassemic Federation of India, New
Delhi Member
8 Shri Gautam Dongre
Secretary, National Alliance of Sickle Cell Disease
NASCO Member
9 Smt. Vinita Srivastava
Advisor, Tribal Health, Ministry of Tribal Affairs Special Invitee
10 Dr. Amitabh Singh
Associate Professor, Pediatrics AIIMS, New Delhi Member Secretary
7. Sub-Committee for Chronic Neurological Disorder
S. No Composition
Committee Designation
1 Dr. Sheffali Gulati
Prof. Child Neurology Division, Dept. of
Pediatric, AIIMS, Delhi Chairperson
2 Dr. Padma Srivastava
HoD, Neurology, AIIMS, Delhi Member
3 Dr. Mina Chandra
HoD, Psychiatry, Dr. RML Hospital Member
4 Dr. Gagandeep Singh
Prof & HoD, Neurology, Dayanand Medical
College & Hospital, Ludhiana Member
5 Dr. Shishir K. Chandan
Sr. CMO
Safdarjung Hospital, Delhi Member
6 Dr. Anand
Principal Consultant & Prof.
Dr. RML Hospital Member
7 Dr. Satish V. Khadilkar
Dean, Medical Faculty, Bombay Hospital,
Institute of Medical Science Member
8 Col. Dr. Aparjita Gupta
MD, Pediatric Neurology, Advance Centre for
Pediatrics, Army Hospital (R&R) Member Secretary
8. Sub-committee for Multiple Disorder
S. No. Composition
Committee Designation
1 Dr. Mina Chandra
HoD Psychiatry ABVIMS & RMLH,
Delhi Chairperson
2 Dr. Sheffali Gulati
Prof, Child Neurology Division,
Department of Pediatrics, AIIMS, Delhi Member
3 Dr. Ajay Gupta
Prof, Dept of Physical Medicine and
Rehabilitation, SJH Member
4 Dr. B.D. Athani
Ex Spl. DGHS, Advisor Member
5 Dr. Satria Beri
HoD Ophthalmology, LHMC & Asso.
Hospital Member
6 Dr. Gautam Bir Singh Member
Dir. Prof. ENT, LHMC
7 Dr. Alok Sud
Director Prof. Dept. of Orthopedics,
LHMC Member
8 Shri Shishir Chandan
Prof., Neurology, SJH Member
Director, NIEPMD, Chennai, Tamil Nadu Member
Director, NIEPVD, Uttarakhand Member
11 Dr. Suvarna Alladi
HoD, Dept. of Neurology, NIMHANS, Bangalore Member
12 Dr. Sharmila B. Mukherjee
Prof. Dept of Pediatric,
LHMC Member Secretary
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