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    Form1a 0

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    vishnu gopan
    This medical certificate document contains 7 questions to assess an applicant's fitness to hold a driver's license. The questions cover vision, color blindness, distance vision, hearing ability, night blindness, and any physical defects. The examining medical officer must note whether the applicant passes each assessment and explain any failures. They then certify whether the applicant is medically fit or unfit to drive based on the examination results.

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    Form1a 0

    Uploaded by

    vishnu gopan
    105 views1 page
    This medical certificate document contains 7 questions to assess an applicant's fitness to hold a driver's license. The questions cover vision, color blindness, distance vision, hearing ability, night blindness, and any physical defects. The examining medical officer must note whether the applicant passes each assessment and explain any failures. They then certify whether the applicant is medically fit or unfit to drive based on the examination results.

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    Form1a_0

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    This medical certificate document contains 7 questions to assess an applicant's fitness to hold a driver's license. The questions cover vision, color blindness, distance vision, hearing ability, night blindness, and any physical defects. The examining medical officer must note whether the applicant passes each assessment and explain any failures. They then certify whether the applicant is medically fit or unfit to drive based on the examination results.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    105 views1 page

    Form1a 0

    Uploaded by

    vishnu gopan
    This medical certificate document contains 7 questions to assess an applicant's fitness to hold a driver's license. The questions cover vision, color blindness, distance vision, hearing ability, night blindness, and any physical defects. The examining medical officer must note whether the applicant passes each assessment and explain any failures. They then certify whether the applicant is medically fit or unfit to drive based on the examination results.

    Copyright:

    © All Rights Reserved
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    of 1

    FORM 1-A

    MEDICAL CERTIFICATE
    [See Rule 5 (1), (3), 7, 10(a), 14(d) and 18 (d)]
    [ To be filled in by a registered medical practitioner appointed for the purpose by the State Government or
    person authorized in this behalf by the State Government referred to under sub-section (3) of Section 8]

    1. Name of the applicant :

    2. Identification Marks :
    (1)
    (2)

    3. (a) Does the applicant to the best of your judgment suffer from any defect
    of vision? If so, has it been corrected by suitable spectacle? YES / NO

    (b) Can the applicant to the best of your judgment readily distinguish
    the pigmentary colours, red and green? YES / NO

    ( c) In your opinion, is he able to distinguish with his eye sight at a distance of


    25 metres in good day light a motor car number plate. YES / NO

    (d) In your opinion the applicant suffer from a degree of deafness which would YES / NO
    prevent his hearing the ordinary sound signals?

    (e) In your opinion does the applicant suffer from night blindness? YES / NO

    (f) Has the applicant any defect or deformity or loss of member which would
    interfere with the efficient performance of his duties as a driver? If so, give YES / NO
    your reasons in details.

    (g)
    OPTIONAL
    (a) Blood Group of the applicant (If the applicant so desires that the information
    may be noted in his driving licence).

    (b) RH factor of the applicant ( If the applicant so desires that the information
    may be noted in his driving licence).

    Declaration made by the applicant in Form – 1 as to his physical fitness is attached.


    I Certify that I have personally examined the applicant

    I also certify that while examining the applicant I have directed special attention to the distant vision
    and hearing ability, the condition of the arms, legs, hands and joints of both extremities of the candidate and
    to best of my judgement he is medially fit / not fit to hold a Driving Licence.
    The applicant is not medically fit to hold a licence for the following reasons :-

    Signature

    1. Name and designation of the


    Medical Officer / Practitioner

    (Seal)

    2. Registration Number of
    Medical Officer

    Date : Signature or thumb-impression of the Candidate

    Note:- The Medical officer shall affix his signature over the photograph affixed in such a manner that part of
    his signature is upon the photograph and part on the certificate.

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