Disability guidelines

रजिस्ट्री स.ं डी.एल.- 33004/99

REGD. No. D. L.-33004/99

स.ं 1272] No. 1272]

EXTRAORDINARY

भाग II—खण्ड 3—उप-खण्ड (ii) PART II—Section 3—Sub-section (ii)

प्राजधकार से प्रकाजित PUBLISHED BY AUTHORITY

नई दिल्ली, बृहस्ट्पजतिार, माचच 14, 2024/फाल्गनु 24, 1945

NEW DELHI, THURSDAY, MARCH 14, 2024/PHALGUNA 24, 1945

सामाजिक न्याय और अजधकाररता मत्रं ालय (दिवयागं िन सिजिकरण जिभाग) अजधसचू ना

नई दिल्ली, 12 माच,च 2024

सी.जी.-डी.एल.-अ.-15032024-253066

xxxGIDHxxx

CG-DL-E-15032024-253066

xxxGIDExxx असाधारण

का.आ. 1338(अ).—के न्रीय सरकार दिंांगिन अजधकार अजधजनयम, 2016 (2016 का 49) की धारा 56 द्वारा

प्रित्त िजि का प्रयोग करते हुए और सामाजिक न्याय और अजधकाररता मंत्रालय, दिंांगिन सिजिकरण जिभाग द्वारा तारीख 25 अप्रलै 2016 को िारी की गई अजधसूचना संख्या 16-21/2013-डीडी-3 और संख्या 16-9/2014-डीडी-3 [का. आ. 76 (अ) तारीख 4 िनिरी, 2018] को अजधक्ांत करते हुए, इसके द्वारा दकसी ंजि में जिजिजनर्िष्च ट दिंांगतां

की सीमा का जनधाचरण करने के जलए जििेषज्ञों की उप-सजमजतयों की जसफाररिों पर जिचार करने के बाि, दकसी ंजि में जनम्नजलजखत जिजनर्िष्च ट दिंांगतां की सीमा का जनधाचरण करने के प्रयोिन के जलए मागिच िशी जस्ांत अजधसूजचत करती ह,ै जिनकाब्यौराउपाबंधमेंदियागयाह,ै अर्ाचत्-

i. गजतजिषयक दिंांगता;

ii. िजृ ि बाजधता;

iii. श्रिण बाजधता और िाक् एिं भाषा दिवयांगता

1914 GI/2024 (1)

456

THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 Disabilities 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 Empowerment 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-committees 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 Disability 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 Union 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 which 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 decide 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. Secy.

ANNEXURE

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 activities 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. Guidelines 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 period 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) Measurement 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

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 457

(d) Measurement of loss of function of hand component consists of determining the prehension, sensation and strength. 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 disability % 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 agreed 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 months 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 component 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 involved, 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 Medical 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 activities:

(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).

(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 and 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%.

458 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

(b) The functional impairment of hand is expressed as loss of prehension, loss 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.

(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 Evaluation 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 conditions (diseases/ injuries etc.) and not to those with congenital anomalies, conditions, loss, or deformities.

For shortening of upper extremity, addition weightage is as follows:

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 459

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) Complications:

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 agreed 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 obtained 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 = higher 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. MOBILITY 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 appropriate weightage given to involvement of proximal and middle joints is as follows:

Hip= up to 35%, Knee= up to 35%, Ankle= up to 20%,

460 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 relation 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 strength in the muscle group.

Numerical Score of Muscle Power

0 1 2 3 4 5

Qualitative Score

Zero

Trace activity Poor

Fair

Good Normal

Loss of strength in %

100

(d) Mean percentage 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 above.

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%

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 461 (b) Pain

Mild (slightly interfering with function) – 3% Moderate (interfering with function) – 6% Severe (grossly interfering with function) – 9%

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 caused 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

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.

ii.

iii.

3.3.2 Cervical Intervertebral Disc Lesions: No. Cervical Intervertebral Disc Lesions

i. Treated case of disc lesion with persistent pain but no neurological deficit

ii. Treated case of disc lesion with pain and instability

Percentage of PPI in relation to the Spine

20%

Posterior element 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%

Severe Dislocation:

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%

Percentage of PPI In relation to Spine

10% 15%

462 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

3.3.3 Thoracic and Thoracolumbar Spine Injuries: No. Thoracic and Thoracolumbar Spine Injuries

i. Compression of less than 50% involving one vertebral body with no neurological manifestation

ii. Compression of more than 50% involving single vertebra or more with involvement of posterior elements, healed, no neurological manifestations persistent pain, fusion indicated

iii. Same as (ii) with fusion, pain only on heavy use of back

iv. Radiologically demonstrable instability with fracture or fracture dislocation with persistent pain

3.3.4 Lumbar and Lumbosacral Spine: Fracture

No. Lumbar and/or Lumbosacral Spine Fracture

i. Compression of 25% or less of one or two adjacent Vertebral bodies, No definite pattern, No neurological Deficit

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.

iii. Radiologically demonstrable instability in low lumbar or Lumbosacral spine with pain

3.3.5 Intervertebral Disc lesion: No. Intervertebral Disc lesion

i. Treated case with persistent pain

ii. Treated case with persistent pain and instability

iii. Treated case with persistent pain and activities of lifting moderately modified

iv. Treated case with persistent pain and stiffness, aggravated by heavy lifting necessitating modification of all activities requiring heavy weightlifting

4. Non-Traumatic Lesions:

Scoliosis and/or Kyphoscoliosis:

Percentage of PPI In relation to Spine

10% 20%

15% 30%

Percentage of PPI In relation to Spine

10% 20%

30%

Percentage of PPI In relation to Spine

10% 20% 25%

30%

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 degrees 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 kyphosis (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.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 463 The percentage of Permanent Physical Impairment is calculated as follows:

Group

Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7

Cobb Angle

10-20 degrees

21-30 degrees

31-50 degrees

51-75 degrees

76-100 degrees 101-125 degrees

126 degrees or greater

% of permanent physical impairment

1to5% 6to9% 10 to 19% 20 to 29% 30 to 39% 40 to 60% 61 to 70%

4.4. A person with scoliosis or kyphoscoliosis should be assessed for cardiorespiratory limitations if present. Additional weightage 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 expansion 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 between 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 different 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 taken 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 around 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 in use for past many years.

No. Maximum Chest Expansion

1. More than 4 cm

2. 3 cm. to 4 cm.

3. 2 cm. to less than 3 cm

4. 1 cm. to less than 2 cm

5. Less than 1 cm.

(b) Counting in a single breath:

%Permanent Physical Impairment

Nil 5 10 15 20

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 recorded 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.

464 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

No. Single breath count (SBC)

1 More than 40

2. 31to40

3. 21to30

4. 11to20

5. 5to10

6. Less than 5

The additional weightage is to be added using combining formula:

where a = higher value, b = lower value.

4.6. Torso Imbalance:

% Permanent Physical Impairment

Nil 5 10 15 20 25

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

1. Upto1.5cm

2. 1.6–3.0cm

3. 3.1–5.0cm

4. 5.1cm or more

No. Head Tilt over C7 spine

1. Up to 150

2. More than 150

%of Permanent Physical Impairment

%of Permanent Physical Impairment 4

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

1. Mild limitation of ADLs

2. Moderate limitation of ADLs

3. Severe limitation of ADLs

* ADL – Activities of Daily Living

(b) Cosmetic Appearance:

– no obvious disfiguration with clothes on – Nil – mild disfigurement – 2%

– severe disfigurement – 4%

%ofPermanent Physical Impairment

4 6 10

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 465

– 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 be 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 any 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

Less than 400 41-500 51-600 61-700 71-800 81-900 91-1000

Permanent Physical Impairment

Nil 10% 20% 30% 40% 50% 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 anterior joint line to the plumb line.

Distance from ankle anterior joint line to the plumb line

Less than 5 cm

5 to 10 cm

10 to 15 cm More than 15 cm

It is added directly.

4.9. Miscellaneous conditions:

% of permanent physical impairment

Up to 4%

Up to 8% depending on distance Up to 16% depending on distance Up to 32% depending on distance

Those conditions of the spine which cause stiffness and pain etc. but are not listed above are rated as follows:

No. Condition

1. Subjective symptoms of pain, no involuntary muscle spasm, not substantiated by demonstrable structural pathology

2. Pain, persistent muscles spasm and stiffness of spine, substantiated by mild radiological changes, and regular need for treatment (medications and non- pharmacological measures)

3. Same as ii. above with moderate radiological changes and regular need for treatment (medications and non-pharmacological measures)

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)

5. Same as iv. above involving the whole spine and regular need for treatment (medications and non-pharmacological measures, interventions)

% of permanent physical impairment

Nil 20

25 30

466 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 formula:

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

1. Fore-quarter amputation

2. Shoulder Disarticulation

3. Trans Humeral (Above Elbow) up to upper 1/3 of arm

4. Trans Humeral (Above Elbow) up to lower 1/3 of arm

5. Elbow disarticulation

6. Trans Radial (Below Elbow) up to upper 1/3 of forearm

7. Trans Radial (Below Elbow) up to lower 1/3 of forearm

8. Krukenberg Operation or Amputation

9. Wrist disarticulation

10. Hand through carpal bones

11. Partial amputation of hand (at the level of shafts of all the metacarpals); thumb intact

12. Thumb through C.M. or though 1st MC joint

13. Thumb disarticulation through metacarpophalangeal Joint or through proximal phalanx

14. Thumb disarticulation through inter phalangeal joint or through distal phalanx

15. Amputation through Proximal phalanx or Disarticulation through MP joint of Index finger

Amputation through Proximal phalanx or Disarticulation through MP joint of Middle finger

Amputation through Proximal phalanx or Disarticulation through MP joint of Ring finger

Amputation through Proximal phalanx or Disarticulation through MP joint of little finger

16. Amputation through Middle phalanx or Disarticulation

% of permanent physical impairment

100

30 25

15 15 5 3 2 10

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण through PIP joint of Index finger

467

Amputation through Middle phalanx or Disarticulation through PIP joint of Middle finger

Amputation through Middle phalanx or Disarticulation through PIP joint of Ring finger

Amputation through Middle phalanx or Disarticulation through PIP joint of little finger

17. Amputation through Distal phalanx or disarticulation through DIP joint of Index finger

Amputation through Distal phalanx or disarticulation through DIP joint of Middle finger

Amputation through Distal phalanx or disarticulation through DIP joint of Ring finger

Amputation through Distal phalanx or disarticulation through DIP joint of little finger

5.3. Lower Limb Amputations:

No. Level of Lower Limb Amputation

1. Hind quarter

2. Hip disarticulation

3. Trans Femoral (Above knee) up to upper 1/3 of thigh

4. Trans Femoral (Above knee) up to lower 1/3 of thigh

5. Through knee

6. Trans Tibial (Below Knee) up to upper 1/3 of leg

7. Trans Tibial (Below Knee) up to lower 1/3 of leg

8. Through ankle

9. Syme’s

10. Up to mid-foot (proximal to tarso-metatarsal joints level)

11. Up to forefoot (distal to tarso-metatarsal joints level)

12. Loss of all toes

13. Loss of first toe

14. Loss of second toe

15. Loss of third toe

16. Loss of fourth toe

17. Loss of fifth toe

4 2 1 5 2 1 1

% of permanent physical impairment

100

3 2 1

6. Guidelines for Evaluation of Permanent Physical Impairment of Congenital deficiencies of the extremities

Congenital limb deficiency simply means 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 1998 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.

468 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 evaluation of PPI in cases of amputees as given in the preceding chapter.

Level

Transverse deficiency Rt. Arm complete (shoulder disarticulation) Transverse deficiency at thigh complete (hip disarticulation) Transverse deficiency Proximal Upper arm (Above elbow) Transverse deficiency at lower thigh (Above knee, Lower 1/3) Transverse deficiency forearm complete (elbow disarticulation) Transverse deficiency lower forearm (Below Elbow)

Transverse deficiency carpal complete (wrist disarticulation)

Transverse deficiency Metacarpal complete (Disarticulation through carpal bones)

LONGITUDINAL DEFICIENCIES

Basic Guidelines

% of permanent physical impairment

90% 90% 85% 80% 75% 65% 60% 55%

6.3. In cases of longitudinal deficiencies of limbs, due consideration shall 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 shortening 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 coordinated 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 components 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 assessed 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 measurement 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 deformity) to 3 (severe deformity).

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 469 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 club 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

00 0.5 3 17

1.5 2 2.5 3 3.5 4 4.5 5 5.5 6

Note:

(i) (ii)

Disability is to be certified as whole number and not as a fraction.

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 absence 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 the 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% interlimb 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; gross 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 method with respect toLymphoedema, the following method is proposed for calculating permanent physical impairment as it has been in use for the past few years.

470

Lymphoedema Grade

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[PART II—SEC. 3(ii)]

Permanent Physical Impairment

Less than 10%

10 – 39% depending on severity within this grade 40 – 50% depending on severity within this grade 51 to 70% depending on severity within this grade

1 2 3 4

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 dislocations, 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 tissues 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 foot 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 severity/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.

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 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/ more than one limb involvement, % PPI is calculated for each limb and then combining formula is used.

(iv) Total disability % will not exceed 100%.

Location and Stage Forefoot

Acute Charcot without deformity 15% Charcot with deformity 20% Charcot with deformity and ulceration 30% Charcot with deformity and osteomyelitis 40%

Note:

(i) Disability is to be certified as whole number and not as a fraction.

Midfoot Rearfoot/Ankle

20% 25% 25% 30% 35% 40% 45% 50%

(iii) . In cases with bilateral limb involvement, % PPI is calculated for each limb and then combining formula is used.

(iv) Total disability % will not exceed 100%.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 471

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 of 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 neurological 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 System 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 people 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 universally 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 Features Score

0 No symptoms at all

1 No significant disability despite symptoms; able to carry out all usual duties and activities

2 Slight disability: unable to carry out all previous activities, but able to look after own affairs without assistance

3 Moderate disability: requiring some help, but able to walk without assistance

4 Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance

5 Severe disability: bedridden, incontinent and requiring constant nursing care and attention

6 Dead

% of Permanent Physical Impairment

Nil

Up to 30% depending on the extent of deficits

40%-50% 51% – 60% 61% – 80% more than 80% Not applicable

472 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

12. Other Chronic Neurological Disabilities/Conditions 12.1. Parkinsonism

In the absence of a standardised 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:

Parkinsonism is an important 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.

Criteria for Rating Impairments of the Upper Extremity: No. Features

1. Individual can use the involved extremity for ADLs involving gross movements but has difficulty with fine movement control of fingers (digital dexterity)

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)

3. Individual can use the involved extremity only as a gross assist in basic ADLs

4. Individual cannot use the involved extremity for basic ADLs

Criteria for Rating Impairments of the Station, Gait and Lower Extremities:

% of Permanent Physical Impairment

Nondominant limb = 20% Dominant limb = 30%

Nondominant limb = 30% Dominant limb = 40%

Nondominant limb = 40% Dominant limb = 50% Nondominant limb = 50 % Dominant limb = 60%

% of Permanent Physical Impairment

Up to 30%

Up to 40% Up to 50% Up to 60%

No.

2. 3. 4.

Features

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

Individual can rise to standing position, can walk some distance with difficulty and without assistance, but is limited to level surfaces, falls are uncommon

Individual rises and maintains standing position with difficulty, cannot walk without assistance, sometimes falls down

Individual cannot stand without help, mechanical support, and/or an assistive device, falls are frequent

In a person with significant involvement 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.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 473 12.2. Extent of Sensory Deficit Physical Impairment

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 impairment:

No. Features

1. Anaesthesia

2. Hypoaesthesia

3. Paraestheis

Extent of Bladder function Deficit

Mild (Hesitancy, Frequency) *

Moderate (Precipitancy)*

Severe (occasional but recurrent incontinence) * Very severe (Retention/Total incontinence) *

* Definitions of bladder dysfunction

% of Permanent Physical Impairment

Up to 10% for each limb

Depending upon % of loss of sensation

Up to 30% depending upon loss of sensation

Percentage of physical impairment

20% (Picture in Mobile) 30%

40%

50%

Terms

Frequency

Urgency

Hesitancy Precipitancy

12.3. Ataxia (Cerebellar)

Definitions

 Increased frequency is defined as those children who void  8 per day.

 Decreased frequency is defined as those children who void  3 per day Sudden and unexpected experience of an immediate and compelling need to void. This

term is not applicable before the attainment of bladder control Difficulty in initiating voiding when the child is ready to void Also known as urinary incontinence.

Defined as involuntary leakage of urine

Austin PF et al The standardization 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.

Refer to chronic neurological 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 of 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. Persons with Spinal Cord Injury are graded on the ASIA (American Spinal Injury Association) Impairment Scale.

The ASIA Impairment Scale:

Level – Type

A = Complete B = Incomplete

Features

No motor or sensory function is preserved in the S4-S5 segments.

Sensory but not motor function is preserved below the neurological level and includes

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THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

C = Incomplete D = Incomplete E = Normal

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 side of the body.

Motor function is preserved below neurological level, and more than half of the key muscles below the neurological level have a muscle grade

Motor function is preserved below neurological level, and at least half (half or more) of the key muscles below the neurological level have a muscle grade >3.

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 is 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 may be assessed under Extent/Natureof Bladder function Deficit Mild (Hesitancy, Frequency) *

Moderate (Precipitancy)*

Severe (occasional but recurrent incontinence) * Very severe (Retention/Total incontinence) *

* Definitions of bladder dysfunction

Percentage of physical impairment

20% 30% 40% 50%

Terms

Frequency

Urgency

Hesitancy Precipitancy

Definitions

 Increased frequency is defined as those children who void  8 per day

 Decreased frequency is defined as those children who void  3 per day Sudden and unexpected experience of an immediate and compelling need to void. This

term is not applicable before the attainment of bladder control Difficulty in initiating voiding when the child is ready to void Also known as urinary incontinence.

Defined as involuntary leakage of urine

Neurological status:

No. Diagnostic Category

% of permanent physical impairment

Tetraplegia (or more specifically, bilateral severe loss of upper extremity function plus the presence of paraplegia

Neurological level C5 or above Neurological level C6 or below

Up to 90% Up to 80%

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 dysfunction

4. Cauda equine-like syndrome with bowel or bladder impairment such as lumbosacral plexopathies

Up to 40% Up to 60%

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 475

(a) Tetraplegia replaced the term quadriplegia in 1992.

(b) Terms such as tetraparesis, quadriparesis, paraparesis are to be avoided.

(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 impairment % 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. The 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 severity 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 cases 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. Scars 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 eyelids 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 loss.

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 narrowed 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 downward, 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 breasts 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.

476 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 description.

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 minor 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 stiff. 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 prolonged 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

Scalp and vault including forehead

Eyebrows (Right & Left)

Deficit

Disfigurement alone

Deformity or full thickness loss Loss of part of one or both Total loss of one or both

% of permanent physical impairment

Cheek and lateral area of face

Breast (Female)

Skin disfigurement

Deformity or full thickness loss

Only skin cover disfigurement Deformity resulting in loss of function due to involvement of

5% each side

5% each

10% each side

3% each

10%

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% each 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 thickness 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

5% 10%

Neck

Skin cover disfigurement

Deformity due to involvement of skin, muscle, or deeper tissue

5% 10%

[भाग II—खण्‍ड 3(ii)]

भारत‍का‍राजपत्र‍:‍असाधारण

i) skin, areola & nipple

ii) Skin, areola, nipple & parenchyma

Only skin cover disfigurement Deformity or full thickness loss

Skin loss resulting in mild deformity Severe contracture of orifices or sloughing of urethra or severe deformity of penis

Only skin cover disfigurement Deformity or full thickness loss

477

Front of trunk & abdomen excluding breast

Total back Groins Buttocks Genitalia

Thigh Lower leg Foot Upper arm Forearm Hand

10% each 5%

2% each 3% each 7%

3% each 3% each 3% each 3% each 3% each 5% each

15% each 10%

10%

5% each 5% each

20%

5% each 5% each 5% each 5% each 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 impairment, 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 Description of Mobility status % of permanent Level physical impairment

478 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 minimal 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 impairments 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 independently 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 activities. 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 limitations 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 over 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 January 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, limitations 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 achievement. 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 help 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 managed 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.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण

479

MACS Level

Features

Handles objects easily and successfully.

Handles most objects but with somewhat reduced quality and/or speed of achievement.

Handles objects with difficulty; needs help to prepare and/or modify activities.

Handles a limited selection of easily managed objects in adapted situations.

Does not handle objects and has severely limited ability to perform even simple actions.

% of permanent physical impairment

20% 30%

40% 55% 70%

Level I Level II

Level III Level IV Level V

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 computed 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 impairment, 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 physical 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 leprosy 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 enable 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

0 No eye problem due to leprosy; no evidence of visual loss

Hands

No anaesthesia, no visible deformity or damage

Feet

No anaesthesia, no visible deformity or damage

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 damage

480 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 (just 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 the 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 higher the Score, greater the Disability. Maximum EHF Score possible to assign is 12. EHF Score

0to1 2to3 4to5 6to7 8to9 10 to 11 12

% of permanent physical impairment

Up to 20% 21 to 40% 41 to 60% 61 to 70% 71 to 80% 81 to 90% 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 PPI 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 gender/sex.

17.2.

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 condition 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 use for the past few years.

Every 1″ vertical height reduction shall be valued as 4% permanent physical impairment in relation to whole body.

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.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 481 Associated skeletal deformities such as contractures or deformities shall be evaluated separately and total percentage

of both shall be added by combining formula.

Height of the Adult

% of permanent physical impairment

Nil 4% 8% 12% 16% 20% 24% 28% 32% 36% 40% 44% 48% 52% 56% 60% 64% 68% 72% 76% 80% 84% 88% 92% 96% 100%

4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 4 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 3 feet 2 feet 2 feet 2 feet

10 inches 9 inches 8 inches 7 inches 6 inches 5 inches 4 inches 3 inches 2 inches 1 inch

11 inches 10 inches 9 inches 8 inches 7 inches 6 inches 5 inches 4 inches 3 inches 2 inches 1 inch

11 inches

10 inches

9 inches or less

or more

SECTION K:

18. Muscular Dystrophy

18.1. Definition: “Muscular dystrophy” means a group of hereditary genetic muscle 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 progressive 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 method is proposed for calculating permanent physical impairment as it has been in use for the past few years.

482 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 to 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 designated 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 person 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 important 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 testing 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 etcUploaded by

19.1. Definition. –Visual impairment

(a)

“blindness” means a condition 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 vision subtending an angle of less than 10 degree in better eye

II. VISUAL IMPAIRMENT

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 483 (b) “Low- vision “means a condition where a person has any of the following conditions, namely: —

(i) Visualacuitylessthan6/18(or20/60)upto3/60(or10/200)bySnellen’schartinthebettereyewith best possible corrections or

(ii) Limitationofthefieldofvisionsubtendinganangleoflessthan40-degreeupto10-degreeinbetter eye (Refer to table no 1).

19.2. Nature of Certificate: The medical authority will decide whether status of disability is temporary 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 condition 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 Impairment 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:

Better eye Best Corrected

Visual acuity: 6/6 to 6/18

Visual acuity: 6/24 to6/60

Visual field less than 40 degrees upto 20 degrees around center of fixation or hemianopia involving macula

TABLE NO.-1

Worse eye

Best Corrected

6/6 to 6/18

6/24 to 6/60

Less than 6/60 to 3/60

Less than 3/60 No Light Perception

6/24 to6/60

Less than 6/60 to 3/60

Per cent Impairment

Disability category

II (One eyed person)

III a (low vision) III b (low vision)

III d (low vision)

0% 10% 20% 30%

40% 50%

Less than 3/60 to No Light Perception

60%

III c (low vision)

Visual acuity: Less than 6/60 to 3/60

Visual field less than20 degrees upto10 degrees around centre of fixation

Lessthan6/60to3/60

70%

Lessthan3/60toNoLightPerception

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 Perception

Only HMCF

Only Light Perception, No Light Perception

100%

IV b (Blindness)

 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 patients’ 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)])

484

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[PART II—SEC. 3(ii)]

Right Eye Right Eye Vision [Best Corrected Visual Acuity (BCVA)]

6/6 to6/18 0%

6/24 6/36

6/60 3/60 2/60

1/60 HMCF to PL-

6/6 to 6/18 6/24

6/36

6/60

3/60

2/60

1/60

HMCF to PL-

 

100%

10%

20%

30%

10%

40%

50%

60%

10%

40%

50%

60%

10%

40%

50%

60%

20%

50%

70%

80%

30%

60%

80%

90%

30%

60%

80%

90%

30%

60%

80%

90%

Yellow-Right eye is better eye; Brown-Left eye is better eye

Percentage of disability is marked 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° 40%

<20°to10°

<40° to 20° <20° to 10°

<10°

100%

50%

60%

50%

70%

80%

60%

80%

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 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 and language disability. The certification medical authority shall comprise of:

I. Medical Superintendent 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

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 485

III. HEARINGIMPAIRMENT AND SPEECH & LANGUAGE DISABILITY

IIIA. HEARING IMPAIRMENT (DEAF AND HARD OF HEARING)

20.1.1 Definition:

(a) “Deaf” mean persons having 70Db hearing loss in speech frequencies 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. Measurement 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 used 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 Audiometry (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 frequency 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 Hearing 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 disability is to be calculated as per the ready reckoner given below separately for Right Ear and Left Ear.

Monaural PTA in dB

0 to 25 26

% of Disability

0 1 1 1

Monaural PTA in dB

61 62 63 64

% of Disability

41.71 43.42 45.13 46.84

486 THE GAZETTE OF INDIA : EXTRAORDINARY

[PART II—SEC. 3(ii)]

29 1

30 1

31 1

32 1

33 1

34 2

35 3

36 4

37 5

38 6

39 7

40 8

41 9

42 10

43 11

44 12

45 13

46 14

47 15

48 16

49 17

50 18

51 19

52 20

53 21

54 22

55 23

56 24

57 25

58 26

59 27

60 40

48.55 50.26 51.97 53.68 55.39 57.1 58.81 60.52 62.23 63.94 65.65 67.36 69.07 70.78 72.49 74.2 75.91 77.62 79.33 81.04 82.75 84.46 86.17 87.88 89.59 91.3 93.01 94.72 96.43 98.14 100

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 affecting 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 treatment)

Percentage of Hearing Disability =

(Better ear% of hearing disability X 5) + (Poorer ear% of hearing disability)

(ii) Glossectomy (assessment for disability after completion of treatment)

(iii) Bilateral vocal cord paralysis (assessment for disability 9-12 months’ post onset)

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 487

(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 documented 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 Intelligibility Affected (SIA) to be measured based on score as the table given below:

Point Description of Speech Sample Scale

1 Normal

2 Can understand without difficulty; however, feel speech is normal

3 Can understand with little effort occasionally need to ask for repetition

4 Can understand with concentration and effort especially by sympathetic listener; require a minimum of two or three repetition.

5 Can understand with difficulty and concentration by family but not others

6 Can understand with effort if content is known

7 Cannot understand at all even when content is known

(b)Voice Test

Percentage of Disability

0-15 16-30 31-39

40-55

56-75 76-89 90-100

Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) (Appendix-V) or Dysphonia Severity Index (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

1 2 3 4 5 6 7

Percentage of overall voice clarity affected (OVCA)

0-15 16-30 31-39 40-55 56-75 76-89 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 Language Components for which Language Disability certificate can be issued  Aphasia

488 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 calculated 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 WAB 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

0 1 2 3 4 5 6 7 8 9

Number in Unit Place in WAB Score

100 98.9 97.8 89.3 88.2 87.2 78.6 77.6 76.5 68.0 66.9 65.8 57.3 56.2 55.2 46.6 45.6 44.5 36.0 34.9 33.9 25.3 24.3 23.2 14.7 13.6 12.5 4.0 2.9 1.9

96.8 95.7 94.6 86.1 85.0 84.0 75.4 74.4 73.3 64.8 63.7 62.6 54.1 53.0 52.0 43.4 42.4 41.3 32.8 31.7 30.7 22.1 21.1 20 11.5 10.4 09.3 0.8 00.0 00.0

The Medical Superintendent or Chief

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.

93.6 92.5 82.9 81.8 72.2 71.2 61.6 60.5 50.9 49.8 40.0 39.2 29.6 28.5 18.9 17.9 8.3 07.2 00.0 00.0

91.4 90.4 80.8 79.7 70.1 69.0 59.4 58.4 48.8 47.7 38.1 37.1 27.5 26.4 16.8 15.7 06.1 05.1 00.0 00.0

20.5. Medical Authority*:

Medical Officer or Civil

Surgeon or any other equivalent authority as notified

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 489

IV. Intellectual Disability, Specific Learning Disorder, Autism Spectrum Disorder

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 characterized 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. Screening

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 psychologists 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

490

a. b. c. d. e.

THE GAZETTE OF INDIA : EXTRAORDINARY

[PART II—SEC. 3(ii)]

0-20: Profound

21 to 35: Severe 36 to 54: Moderate 55-69: Mild 70-84: Borderline

100% disability 90% disability 75% disability 50% disability 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 Rehabilitation Psychologist

21.8. Validity of Certificate:

Temporary certificate for children less than 5 years:

Below the age 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 more 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

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Section B: Specific Learning Disability

22.1. Definition

Specific learning disabilities 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 calculations 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.

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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 require 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: Clinical 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 examination, 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 Psychiatrist: 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 psychologists 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 specific 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. These 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 vision 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 current class on NIMHANS battery or his/ her GLAD score is below 40%, for the child’s current class level.

22.4. Medical Authority*

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)

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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 Class 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

Makes mistakes in reading like – Omits words

– Substitutes words

– Adds words

– Skips lines

– Reads sentences repeatedly

Can answer questions orally but has difficulty in writing answers

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[PART II—SEC. 3(ii)]

Writes or reads figures or letters in wrong way, for example, 15 for 51, 6 for 9, b for d

Difficulty in differentiating letter sounds for vowels and blends, example “E” for “I’; “ch” for “sh”;

Oral work is better than written work

Difficulty in rhyming words and repeating them

Reads in past tense, while the text is written in present tense or vice-versa; example replaces “is” with “was”

Changes the sequence of alphabets while reading; example says “neerg” instead of “green”

Replaces long words with compact one; example “musim” for “museum”

Difficulty in taking notes or copying them from blackboard and books

10.

Confusion 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.

*Sometimes: upto 6-7 times in 2-3 months

Writes in mirror images; example “ram”- “mar”

** Frequently: More than 7 times in 2-3 months

Figure 2. Details of assessment for a child with specific learning disability

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 495

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. Diagnosis

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.

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23.3. Disability Calculation

Children <6years

All children with an autism spectrum disorder in the age group <6 years will be assessed and 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 Scale of Assessment of Autism Score

Disability Percentage

40 to 59% disability 60 to 79% disability ≥80% disability

a) Mild Autism (ISAA Score 70 to 106)

b) Moderate Autism (ISAA Score (107 to 153)

c) Severe Autism (ISAA Score >153)

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. 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) 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)

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, reassessment 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.

V. Mental Illness

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 include 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, clinical assessment, IDEAS scale and/or IQ assessment.

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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 IDEAS 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 responsible 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 certification.

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 health 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 residual 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 certification 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 treatment, preserve medical records and repeat disability certification after 2 years.

24.4. MEDICAL AUTHORITY*:

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 Clinical Psychologist/Rehab Psychologist/Psychiatric social worker (wherever required Psychological Assessment report from RCI registered Psychologist obtained in last three months).

VI. CHRONIC NEUROLOGICAL CONDITIONS

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.

498

2. 3.

4. 5.

6. 7.

9. 10.

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These guidelines should only be used for central and upper motor neuron lesions.

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 reassessment after two years from the first assessment for the permanent certification.

Total percentage of physical impairment in any neurological condition shall not exceed 100%.

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

Additional 10% will be given for involvement of dominant upper extremity.

Additional weightage up to 10% can be given for loss of sensation in each extremity but the total physical impairment should not exceed 100%.

Neurological conditions which are reversible and without sequelae are not certifiable. Only 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.

The disability certificate should mention name of the Chronic Neurological Condition. (Clinical Diagnosis/Name of the disease, the nature, and the extent of disability as far as possible).

Permanent disability certificate can be issued in a few irreversible/progressive cases, if required for certain specific needs/requirements by the person with disability 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 Medical Board or as specified by Law.

11.

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 Disease, 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 antibody disease).

3. Paraneoplastic Syndromes

4. Chronic Drug Refractory Epilepsy *

. The disability certificate shall clearly mention the name of the Chronic Neurological Conditions

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 499 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, cognition (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 follow 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 conclusive 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 functional 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 assessment 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 total 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 neurological 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 from 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

Score 0-10Mild (Detected on examination)

Score 11-20Moderate

Score 21-30Severe Score 31-40Very Severe

Physical Impairment

25% 50% 75% 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 total 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 percentage 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 Movement disorders like Neuronal Brain Iron Accumulation, Wilson disease, Huntington’s chorea, Genetic Dystonia etc.

Assessment of dystonia requires objective scoring.

500

Severity of Dystonia

Mild (present occasionally)

Moderate (present most time of the day) Severe (present continually)

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Physical impairment 25%

50%

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.

Severity of Chorea

Mild Individual can use the involved extremity for activities of daily living

(ADL) involving gross movements but has mild difficulty in fine movements

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

Severe Individual requires assistance in the involved extremity for activities of daily living (ADL) with severe difficulty involving gross movements and has severe difficulty in fine movements

25.4.5. Parkinsonism-

Physical impairment

Non dominant limb-20% Dominant limb-30%

Non dominant limb-30% Dominant limb-40%

Non dominant limb-50% Dominant limb-60%

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 assessment 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)

1.5

2 30% 2.5 40%

3 50%

4 Severe impairment 75%

5 100%

25.4.6. For Motor Neuron Disease like Amyotrophic lateral sclerosis: Functional rating scale for ALS (Appendix-XVI) may be applied as

Stage

Modified Hoehn and Yahr Scale

Physical Impairment

Unilateral involvement only

10% 20%

Unilateral and axial involvement

Bilateral involvement without impairment of balance

Mild bilateral disease with recovery on pull test

Mild to moderate bilateral disease; some postural instability; physically

independent

; still able to walk or stand unassisted

Wheelchair bound or bedridden unless aided

Functional score

0-15 16-30 29-40 40-48

Percentage of physical impairment

Severe 80-100% Moderate 60-79% Mild 40-59% Very mild<40%

25.4.7. For Neuropathy & Myopathy the following assessment may be used Functional ability

No significant impairment

Able to carry out all usual activities, despite some symptoms

Mild impairment

Percentage of physical impairment

<40% 40-50%

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 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

Severe impairment

Requires constant nursing care including use of assisted respiratory devices and is bed ridden

501

51-60% >80%

25.4.8. Bladder dysfunction may be assessed under the broad heading of Chronic Neurological Disease

Extent/Nature of Bladder Function Deficit

Mild (Hesitancy, Frequency) *

Moderate (Precipitancy)*

Severe (occasional but recurrent incontinence)* Very severe (Retention/Total incontinence)*

*Definitions of bladder dysfunction

Percentage of physical impairment

20% 30% 40% 50%

Terms

Frequency

Urgency

Hesitancy Precipitancy

Definitions

 Increased frequency is defined as those children who void  8 per day

 Decreased frequency is defined as those children who void  3 per day Sudden and unexpected experience of an immediate and compelling need to void. This

term is not applicable before the attainment of bladder control Difficulty in initiating voiding when the child is ready to void Also known as urinary incontinence.

Defined as involuntary leakage of urine

25.4.9. Scoring method for disability in epilepsy

Severity of disability

Mild Moderate Severe Very severe

Numbers of convulsion

One convulsion only 1-5/months 6-10/months >10/months

Disability percentage

Nil 25 50 75

25.4.10. Cognitive dysfunction- In children assessment of 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 chronic 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 impairment 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

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Type of Cranial Nerve

Isolated Motor Cranial Nerve Isolated Sensory Cranial Nerve

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Degree of Impairment 20% for each 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 Parkinson’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 exceed 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 members:

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 Specialist 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 coopted as the case may demand

Diseases covered: A. Hemophilia

B. Thalassemia

VII. DISABILITY CAUSED DUE TO BLOOD DISORDERS

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. The 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

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 503

manage their disease. With good treatment, some improvement in their symptom burden 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 will 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 standard 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 progression.

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 DISABILITY 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 occur 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 extended 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 than 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 case 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 severe 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.

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26.3. Type of certificate

● 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 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).

26.4. Investigations for the basis of diagnosis 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 Factor 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 required 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. Factor 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 score assignment to patients with hemophilia (Blood disorder)

Measured Disability Factor VIII or

Score (%) IX level Clinical Criteria$

Select only one

1. 1

5-50% (factor VIII or IX)

History of significant bleeding during injury or surgery BUT no deformity and no severe chronic pain# due to the disease

2. 2

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

<5%

(factor VIII or IX)

Hemophilia +

Documentation of two or more

bleeds in any MAJOR JOINT* or muscles

<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%

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

[भाग II—खण्‍ड 3(ii)]

भारत‍का‍राजपत्र‍:‍असाधारण 505

<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#

<5%

Hemophilia =Intracranial OR psoas bleed causing neurological sequelae leading to difficulty in usage of ONE limb or presence of a Pseudotumor

<5%

Hemophilia =Intracranial OR psoas bleed or pseudotumor causing neurological sequelae leading to difficulty in usage of TWO limbs

9. 70

10. 75

11. 80

<5% Hemophilia =Can’t stand independently BUT can walk, but

with the help of ONE crutch

<5% Hemophilia =Can’t stand independently BUT can walk, but

with the help of TWO crutches

<5% Hemophilia =Wheelchair bound due to hip OR spine disability OR

paralysis of the lower limbs

12.

<5%

Hemophilia =Wheelchair bound due to hip OR spine disability OR paralysis of the lower limbs AND inability to use the dominant upper limb

13.

<5%

Hemophilia =Bed bound (confined to bed) AND inability to sit up AND inability to use the dominant upper limb

but without vision and /or hearing impairment

14.

<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 hearing 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]

506 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

If transfusion-transmitted infection (TTI) is present the following additional score will 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 / specialist 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 (on or off treatment) = 5 HBV Infection (on treatment) = 5 HCV infection (on treatment) = 5 None = 0

Select if indicated

# 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

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 document (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 performing 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 retained 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 progression 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 disorders 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 severity. 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 requirement, 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 without

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 507 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 many 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 some 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 cures 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 performed 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 disability 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 associated 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 infancy and are required life- long at an interval of 2-3 weeks. Severe organ dysfunction occurs as a consequence to severe iron overload/ 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 major 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).

508 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

27.5. Investigation basis of diagnosis of Thalassemia 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 status. 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 treating 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 thalassemia 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 number 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 members or doctor

Persons can be reassessed on request of patient or family or doctor’s advice; or when the individual will no longer be eligible for disability certificate post successful bone marrow transplant or post Gene Therapy or gene editing (whenever available). 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.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 509

27.9. Investigation basis of diagnosis of Thalassemia intermediaandsupporting documentation 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. Documentation 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

510 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 criteria 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 transfusion (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

0358 3 Endocrine Dysfunction (requires tests reports)

Diabetes Mellitus

Thyroid Dysfunction

Parathyroid Dysfunction

Growth abnormality

Gonada l dysfunc tion

Osteo por- osis

222223

Transfusion associated infections # (HIV / HBsAg/ HBV DNA/ HCV RNA)

(Hospital Documentation 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

*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 2

NYHA Class 3

NYHA Class 4

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 511 505050

NYHA Class 1

0 Yes No Yes No Yes No Yes No 10305080

6 Hepatobiliary (see Appendix- XVIII for grading)

CTP

< 5 points 0

CTP Class A CTP Class B

(5-6 points) (7-9 points)

Yes no Yes No 305080

CTP Class C (10-15 points) Yes No

7. Kidney (see Appendix-XIX for grading)

eGFR > 90 eGFR 90-45 eGFR 45-15 eGFR less than 15 0358

8 Pain

PDQscore No or minimal

pain

Mild pain

PDQ Score (11- 70)

Moderate PDQ Score (71-100)

Severe

PDQ Score (101- 130)

Extre me

PDQ Score

(131- 150)

PDQ Score XX) (0-10)

Total score 1 to 8 =

If criteria forother disabilityfulfilled, then assessment as per other disability guidelines to be performed and patient assessed by multi-disability board (see section VIII). Do not merely add the scores.

(Appendix –

No Yes No Yes No 0020305080

Yes No Yes

Yes No

9 Neurological

Score as per the neurological disability guideline Or not applicable =0

Multiple disability board

512

Locomotor

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[PART II—SEC. 3(ii)]

Score as per the locomotor disability guideline Or not applicable =0

Multiple disability board

Other disability – Vision impairment, Hearing impairment, Growth failure Score as per the locomotor disability guideline

Or not applicable =0

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 percent 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 treatment. 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 complications.

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 scan, 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 appropriate 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 scoring 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 inherited 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 (SCD), but they can pass the trait on to their children. The sickle cell trait in the present guideline will get a score of 5 %.

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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 /Homozygous 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 status, 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 mutation 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 carrier 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 disease 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 alter 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 disability

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 various complications due to associated tissue and organ damage; “hemolytic” refers to the destruction of the cell membrane of red blood cells resulting in the release of hemoglobin.

28.3 Sickle cell disease is caused by a variant hemoglobin disorder. The abnormal 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 quality of life due to crises and organ damage.

The patients inherit this disorder which is 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 in 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 certificate post successful treatment with gene therapy/ gene editing (whenever applicable).

514 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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 transfused 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 or 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 complications 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 seen 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 eligible 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 editing (whenever available).

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 515

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 transfused 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 mutation 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 transfusions 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 penicillin 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. Hematopoietic 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 conditioning 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 (%)

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 sickle D= 40%

Other compound heterozygote sickle cell syndromes

=30%

Pain (chronic pain includes backpain, priapism, avascular necrosis (AVN), or any other sickle disease-

associated pain)

02358

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 55

Endocrine Dysfunction

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)

Diabetes Thyroid Parathyroid Growth Gonadal Mellitus Dysfunction Dysfunction abnormality dysfunction 222223

Osteopo rosis

516

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[PART II—SEC. 3(ii)]

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 should be referred for treatment

HIV HBV Infection HCV infection (on therapy) Infection (on therapy)

555

*Cardiopulmonary Dysfunction and /or fatigue (checkhemoglobin is at steady state) – examine for cardiac failure, cardiac hemosiderosis, pulmonary arterial Hypertension, chronic lung disease (see Appendix- XVII for how to grade)

Asymptom NYHA NYHA Class 2 NYHA Class 3 NYHA Class 4 atic Class 1 01358

Hepato-biliary dysfunction (see Appendix-XVIII for how to grade)

CTP CTP CTP Class B CTP Class C < 5 points Class A (7-9 points) (10-15 points)

(5-6

points)

0358

Kidney dysfunction (see Appendix -XIX for how to grade)

eGFR > 90 eGFR eGFR 45-15 eGFR less than 15 90-45

0358

Total score 1-9

If multiple 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.

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.

Score as per the neurological disability guideline Or

Not applicable=0

Locomotor (AVN, paralysis, osteomyelitis etc.)

Score as per the locomotor disability guideline Or

Not applicable=0

Ophthalmological complication

Diminished As per the visual disability assessment vision Or

Not applicable=0

Total Final score

Multiple disability board

*Cardiac function should be assessed when the patient is hemodynamically stable, and dysfunction is not due to acute anaemia

Criteria 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 positive 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 needs review in multiple-disability board. If multiple disabilities are present- then the total is as per the formula given in.

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 517

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 following: –

(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.

A Benchmark disability of 40% is assigned to the patients fulfilling the diagnostic criteria 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 applicant 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) :

__________________ __________________ __________________ _________________________________________________________

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(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 disability :

(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 strike 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 editing

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 inaccuracy 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 Therapy 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 institution be enclosed.

4. Two recent passport size photographs.

Upon reassessment of the disability:

(For office use only)

(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: ______________________

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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 injury 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 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. 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 records 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-

520

THE GAZETTE OF INDIA : EXTRAORDINARY

[PART II—SEC. 3(ii)]

Vision impairment Hearing impairment Growth failure Locomotor disability Neurological involvement

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 signatory. 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 (government 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 calculation) 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. PDQ 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, cognitive 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, Autism Spectrum Disorder etc.

VIII. MULTIPLE DISABILITIES

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण 521

(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 multiple 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 severe. 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 with 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 given 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 score 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.

=58%

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Such calculation will continue till the last disability (with severity score more than or equal to 25%) is covered. The final figure 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 disability 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 and 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 disability 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 assessment 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, Developmental disorders, Mental illness and Chronic Neurological Disorders.

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)

=79%

Appendix No

I. II.

Subject

Muscle Strength Grading (Medical Research Council- MRC scale)

Form A Assessment Proforma for Upper Extremity

If Free or Copy righted

Freely Available** Freely Available**

[भाग II—खण्‍ड 3(ii)] भारत‍का‍राजपत्र‍:‍असाधारण Form B Assessment Proforma for Lower Extremity

III. Average Normal Range of Motion (degrees) at Different Joints:

IV. Perceptual Speech Intelligibility Rating Scale (AYJNISHD, 2022)

V. Consensus Auditory Perceptual Evaluation of Voice (CAPE-V)

VI. Vineland Social Maturity Scale

VII. Malin’s Intelligence Scale for Indian Children (MISIC)

IX. NIMHANS Index for SLD

X. Grade Level Assessment Device for Children with Learning Problems in School- GLAD (NIEPID)

XI. AIIMS-Modified INCLEN Diagnostic Tool for ASD

XII. Indian Scale for Assessment of AUTISM

XIII. Indian Disability and Assessment Scale(IDEAS)

XIV. Scale for the Assessment and Rating of Ataxia (SARA)

XV. Modified Hoehn and Yahr Scale

XVI. ALS Functional Rating Scale Revised (ALS-FRS-R)

XVII.

XVIII. CTP Calculation

XIX. EGFR Calculation

XX. Pain Disability Questionnaire (PDQ)

523

Freely Available** Freely Available**

Freely Available** Copyrighted Copyrighted

Copyrighted Freely Available**

Freely Available** Freely Available** Freely Available** Freely Available** Freely Available** Freely Available** Freely Available**

Freely Available** Freely Available** Freely Available**

VIII.

A.WISC -IV Wechsler’s Scale for Children …… B. Binet Kamat Test ( BKT)…………………….. C. NIEPID IQ TEST …………………………….

Copyrighted Copyrighted Freely Available**

The New York Heart Association (NYHA) Functional

Classification

Note**:- The Latest versions of freely available tests should be used as updated from time to time.

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536 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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538 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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540 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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542 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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548 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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550 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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552 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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554 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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556 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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558 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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560 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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562 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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566 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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608 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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618 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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624 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

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[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 629

630 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 631

632 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 633

634 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 635

636 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 637

638 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 639

640 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 641

642 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 643

644 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 645

646 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 647

648 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 649

650 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 651

652 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 653

654 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 655

656 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 657

658 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 659

660 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 661

662 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 663

664 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 665

666 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 667

668 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 669

670 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 671

672 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 673

674 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 675

676 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 677

678 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 679

680 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 681

682 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 683

684 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 685

686 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 687

688 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 689

690 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 691

692 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 693

694 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 695

696 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 697

698 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 699

700 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 701

702 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 703

704 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 705

706 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 707

708 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 709

710 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 711

712 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 713

714 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 715

716 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 717

718 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 719

720 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 721

722 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 723

724 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 725

726 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 727

728 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 729

730 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 731

732 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 733

734 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 735

736 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 737

738 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 739

740 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 741

742 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 743

744 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 745

746 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 747

748 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 749

750 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 751

752 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 753

754 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 755

756 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 757

758 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 759

760 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 761

762 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 763

764 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 765

766 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 767

768 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 769

770 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 771

772 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 773

774 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 775

776 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 777

778 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 779

780 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 781

782 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 783

784 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 785

786 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 787

788 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 789

790 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 791

792 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 793

794 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 795

796 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 797

798 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 799

800 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 801

802 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 803

804 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 805

806 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 807

808 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 809

810 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 811

812 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 813

814 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 815

816 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 817

818 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 819

820 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 821

822 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 823

824 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 825

826 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 827

828 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 829

830 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 831

832 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 833

834 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 835

836 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 837

838 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 839

840 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 841

842 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 843

844 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 845

846 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 847

848 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 849

850 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 851

852 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 853

854 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 855

856 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 857

858 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 859

860 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 861

862 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 863

Sub-committees for Review of Guidelines for Purpose of Assessing the Extent of Specified Disability in a person 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 Director General, Dte.GHS

Following sub-committees were constituted to revise the Assessment Guidelines for Disability-

S No 1

2 3 4 5 6

S No 1

2 3 4 5 6 7

Sub-Committee on Mental Illness

Composition

Prof. Pankaj Verma

HoD, Psychiatry, SJH, Delhi

Dr. Mina Chandra

HoD, Psychiatry, ABVIMS & RMLH

Dr. Smita Despande

Ex Psychiatrist RMLH, Advisor

Dr. Manushree Gupta

Associate Prof. SJH, Delhi

Ms. Pragati Pandey

Asst. Prof. NIMHR

Dr. Rohit Verma

Asst. Prof. Department of Psychiatry, AIIMS, Delhi

Sub-Committee on Locomotor Disability

Composition

Dr Sanjay Wadhwa

Prof. & HoD, Dept. of PMR, AIIMS Dr. Ritu Mazumdar

HoD PMR, LHMC & KSCH

Dr. B.D. Athani

Ex Spl. DGHS, Advisor,

Dr. Satish Kumar

HoD Orthopedic, Dr. RMLH

Dr. Shishir Chandan

Prof. Neurology, SJH,

Dr. Desh Deepak

Consultant Respiratory Medicine Dr. Ajay Raj

Committee Designation Chairperson

Member

Member Secretary

Committee Designation Chairperson

Member Member Member Member Member Member

864

THE GAZETTE OF INDIA : EXTRAORDINARY

[PART II—SEC. 3(ii)]

8 9

10 11

3. SL.No.

2 3 4 5

4. S. No.

1 2 3 4

5. S. No.

Prof. Cardiology, Dr. RMLH

Dr. Sameek Bhattacharya

Burn & Plastic, Dr RML Hospital Shri T.D Dhariyal

Former Deputy Chief Commissioner, GoI and State Commissioner for PwD, Delhi

Director

SVNIRTAR, Cuttack

Dr, Suman Badhal Prof, PMR SJH,

Sub-Committee on Visual Impairment Composition

Dr. Ritu Arora

Dir. Prof. Ophthalmology Dean,

Maulana Azad Medical College, New Delhi Dr. Sarita Beri

HoD Ophthalmology, LHMC & Asso. Hospital Dr. Radhika Tandon

Prof. Ophthalmology, AIIMS

Dr. Rajiv Garg

Ex DGHS, Adviser

Director

NIEPVD, Uttarakhand

Dr Anuj Mehta

Prof, Dept of Ophthalmology, Safdarjung Hospital

Sub-Committee on Hearing Impairment Composition

Dr. Arunbha Chakravrti

Director & Prof, Dept. of ENT, LHMC Dr. Isha Preet Tuli

Prof. ENT, VMMC & SJH

Director

AYJNISHD, Mumbai

Mr. Parbhakar Upadhyay

Audio Metrician, Dept. of ENT, LHMC

Sub-Committee on Developmental Disorder Composition

Dr. Dr. Sheffali Gulati

Prof. Child Neurology Division, Department of

Member Member

Member

Member Secretary

Committee Designation Chairperson

Co-Chairperson Member Member Member

Member Secretary

Committee Designation Chairperson

Member

Member Secretary

Committee Designation Chairperson

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 865

2 3

4 5 6

6. S. No.

1 2 3

4 5

6 7

9 10

Pediatrics, AIIMS, Delhi

Dr. Mina Chandra

HoD, Psychiatry, ABVIMS & RMLH

Dr. Paul Russell

Professor & lead Consultant, CMC Vellore, Tamilnadu

Dr. Sharmila B. Mukharjee

Prof. Dept. of Pediatric, LHMC, Delhi

Director, NIEPID, Secunderabad, Telangana Dr. Madhuri Kulkarni

Ex Head Dept. of Pediatrics, L.M.M. Medical College, Maharashtra

Dr. Vishal Sondhi

Prof. Department of Pediatrics, AFMC, Pune

Sub-Committee on Blood Disorder Composition

Dr. Tulika Seth

Prof. Dept. of Hematology, AIIMS, Delhi

Dr. Dipty Jain

Ex HoD, Dept of Pediatrics, GMC, Nagpur

Dr. Cecil Ross

Prof. of Medicine and Hematology, St. Johns Medical College Hospital, Bangalore

Dr. Prantar Chakraborty

Consultant, Clinical Haematology, Vivekananda Institute of Medical Sciences

Shri TD Dhariyal

Former Deputy Chief Commissioner, GoI and State Commissioner for PwD, Delhi

Dr. Ritika Sud

Prof. Medicine LHMC, New Delhi

Ms. Shobha Tuli

President Thalassemic Federation of India, New Delhi

Shri Gautam Dongre

Secretary, National Alliance of Sickle Cell Disease NASCO

Smt. Vinita Srivastava

Advisor, Tribal Health, Ministry of Tribal Affairs Dr. Amitabh Singh

Associate Professor, Pediatrics AIIMS, New Delhi

Member Member

Member Member Member

Member Secretary

Committee Designation Chairperson

Member

Member Member

Member

Special Invitee Member Secretary

866

THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(ii)]

S. No 1

2 3 4

5 6 7 8

S. No. 1

2 3

4 5

Sub-Committee for Chronic Neurological Disorder

Composition

Dr. Sheffali Gulati

Prof. Child Neurology Division, Dept. of Pediatric, AIIMS, Delhi

Dr. Padma Srivastava

HoD, Neurology, AIIMS, Delhi

Dr. Mina Chandra

HoD, Psychiatry, Dr. RML Hospital

Dr. Gagandeep Singh

Prof & HoD, Neurology, Dayanand Medical College & Hospital, Ludhiana

Dr. Shishir K. Chandan

Sr. CMO

Safdarjung Hospital, Delhi

Dr. Anand

Principal Consultant & Prof.

Dr. RML Hospital

Dr. Satish V. Khadilkar

Dean, Medical Faculty, Bombay Hospital, Institute of Medical Science

Col. Dr. Aparjita Gupta

MD, Pediatric Neurology, Advance Centre for Pediatrics, Army Hospital (R&R)

Sub-committee for Multiple Disorder

Composition

Dr. Mina Chandra

HoD Psychiatry ABVIMS & RMLH, Delhi

Dr. Sheffali Gulati

Prof, Child Neurology Division, Department of Pediatrics, AIIMS, Delhi Dr. Ajay Gupta

Prof, Dept of Physical Medicine and Rehabilitation, SJH

Dr. B.D. Athani

Ex Spl. DGHS, Advisor

Dr. Satria Beri

HoD Ophthalmology, LHMC & Asso. Hospital

Dr. Gautam Bir Singh

Committee Designation Chairperson

Member Member Member

Member

Member Secretary

Committee Designation Chairperson

Member Member

Member

[भाग II—खण्‍ड‍3(ii)] भारत‍का‍राजपत्र‍‍णराधारअ‍: 867

Dir. Prof. ENT, LHMC

7 Dr. Alok Sud

Director Prof. Dept. of Orthopedics,

LHMC

8 Shri Shishir Chandan

Member

Member Secretary

9 10

Prof., Neurology, SJH

Director, NIEPMD, Chennai, Tamil Nadu

Director, NIEPVD, Uttarakhand

11 Dr. Suvarna Alladi

HoD, Dept. of Neurology, NIMHANS, Bangalore

12 Dr. Sharmila B. Mukherjee

Prof. Dept of Pediatric, LHMC

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