Form C4 - Application For Normal Retirement - 2011 Page 10
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2208/11
3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016
(602) 255-5575 FAX (602) 296-2369
ORDINARY
DISABILITY QUESTIONNAIRE
Completed by Local Board and Doctor (if applicable)
Pursuant to A.R.S. §§ 38-881(30) and 38-886.01, an "Ordinary disability" means a physical condition that the local
LOCAL
board determines will totally and permanently prevent an employee from performing a reasonable range of duties
BOARD
within the employee's department or a mental condition that the local board determines will totally and permanently
Initial
prevent an employee from engaging in any substantial gainful activity.
Response
Did the employee file the application after the disabling incident or within one year of ceasing to be an
1.
employee?
YES
NO
Does the employer have any jobs available for the member the board believes is a reasonable range of
2.
duties position? (Submit job descriptions and duties to doctor.)
YES
NO
3.
Has the member refused a job the board believes is a reasonable range of duties?
YES
NO
Did the employer terminate the employee’s employment based on a physical or mental condition that is
4.
being applied for?
YES
NO
5.
Did the employer terminate the employee’s employment based on a disciplinary issue?
YES
NO
6.
Did the member terminate employment based on a physical or mental condition?
YES
NO
Did the member terminate employment based on election to participate in Reverse DROP?
7.
YES
NO
Does the physical condition totally prevent the member from performing a reasonable range of duties
8.
within the employee’s department?
YES
NO
Does the physical condition permanently prevent the member from performing a reasonable range of
9.
duties within the employee’s department?
YES
NO
10.
Does the mental condition totally prevent the member from engaging in any substantial gainful activity?
YES
NO
Does the mental condition permanently prevent the member from engaging in any substantial gainful
11.
activity?
YES
NO
LOCAL BOARD INSTRUCTIONS: If it is determined that the employee does not qualify, complete FORM C5-LB and forward to CORP.
If evidence exists that the employee may qualify and no reasonable range of duty jobs are available, a medical examination (IME) will
need to be performed. Sign/date this questionnaire and forward the ORIGINAL (along with the all medical evidence and any additional
questions) to the doctor.
DOCTOR INSTRUCTIONS: In addition to the IME report, answer the following questions, sign/date and return
DOCTOR
the ORIGINAL to the Local Board. Provide additional comments in the IME report.
Initial Response
1.
Does the member have the physical or mental condition that is the basis for the disability application?
YES
NO
Does the physical condition permanently prevent the member from performing a reasonable range of
2.
duties within the employee’s department?
YES
NO
Does the physical condition totally prevent the member from performing a reasonable range of duties within
3.
the employee’s department?
YES
NO
4.
Does the mental condition totally prevent the member from engaging in any substantial gainful activity?
YES
NO
Does the mental condition permanently prevent the member from engaging in any substantial gainful
5.
activity?
YES
NO
6.
Are there conflicts in the medical evidence? If yes, address in IME report.
YES
NO
LOCAL BOARD: If conflicts in the medical evidence, address if and how they were resolved in the Local Board meeting minutes.
LOCAL BOARD AND DOCTOR: By my signature below, I attest that the medical records have been thoroughly reviewed, each
section/questions have been answered by the appropriate party indicated above, and the information contained herein is true, complete
and correct to the best of my knowledge and belief.
PRINT Name of Local Board Secretary or Chairman
Signature
Date
PRINT Doctor Name
Signature
Date
Rev. 07/07/2011
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