MEDICAL CERTIFICATE FOR DEAF


	The land of the Dancing Deer

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GOVERNMENT OF MANIPUR

DEPARTMENT OF SOCIAL WELFARE

MEDICAL CERTIFICATE FOR THE DEAF

Certified that I, Dr. ……………………………………… Registration No. ………………..
have this ……………………………… day of …………………… 19 ……….. , examined the applicant whose particulars are given below :

1. Name of candidate :-
2. Father’s name:-
3. Sex:
4. Approximate age:
5. Identification marks:-
6. An estimate of the residual rearing, if any and the basis on which
this estimate has been arrived at

i. Right ear
ii. Left ear

1. Onset of deafness (Please state whether deafness in from birth or acquired later. If it has been
caused afterwards the age and cause of deafness may be indicate).
(For the purpose of scholarship the deaf are those in whom the sense of bearing is non- function
for the ordinary purpose of life. Generally lose of hearing at 70 decibels or above 500,1000, 2000 frequencies will make residual hearing non-functional).

2. Please state clearly whether the candidate is deaf for the purpose of scholarship.
3. Please enclose audiogram chart.

Signature of Candidate                                             (Signature of E.N.T Specialist)

                                                                                Designation:

Place:                                                                      Office Stamp:

                                                                              Address: