Medical Certificate for the Deaf

                                Certified that I, Dr. …………………………………………………………

Registration No………………………………………….. have this……………………………

Day of ……………………………………200..                  examined the candidate whose particulars are given below.

1.        Name of candidate

2.        Father ‘s name  

3.        Sex  

4.        Approximate  

5.        Identification mark

6.          An estimate of the residual hearing if any and the basis        

         on which this estimate has been arrived at .  

         i)          Right ear

ii)                   Left ear.

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

8.        Please state clearly whether the candidate  is deaf for the purpose of scholarship.

 9.     Please enclose audiogram chart.

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

Place                                                                                               Designation    

Date                                                                                                Office Stamp               

                                                                                                        Address