Form C4 - Application For Normal Retirement - 2011 Page 8
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22CORRECTIONS OFFICER RETIREMENT PLAN
FORM C5-LB-A
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016
(602) 255-5575 FAX (602) 296-2369
ACCIDENTAL
DISABILITY QUESTIONNAIRE
Completed by Local Board and Doctor (if applicable)
Pursuant to A.R.S. §§ 38-881(1) and 38-886, an "Accidental disability” means a physical or mental condition that
the local board finds totally and permanently prevents an employee from performing a reasonable range of duties
LOCAL
within the employee’s department, was incurred in the performance of the employee's duties and was a result of
BOARD
physical contact with inmates, prisoners, parolees or persons on probation, responding to a confrontational
Initial
situation with inmates, prisoners, parolees or persons on probation, or a job-related motor vehicle accident while
on official business for the employee's employer.
Response
Did the employee file the application after the disabling incident or within one year of ceasing to be an
1.
employee?
YES
NO
2.
Is the employee still working in a job the board believes is a reasonable range of duties?
YES
NO
Does the employer have any jobs available for the employee the board believes is a reasonable range of
3.
duties position? (Submit job descriptions and duties to the doctor if sent for IME.)
YES
NO
4.
Did the employer terminate the employee’s employment based on a physical or mental condition?
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
7.
Did the member terminate employment based on election to participate in Reverse DROP?
YES
NO
8.
Has the member refused a job the board believes is a reasonable range of duties?
YES
NO
Was the injury the result of an event incurred during the performance of the member’s duty detailed above?
9.
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 condition that is the basis for the disability application?
YES
NO
2.
Does the member have the mental condition that is the basis for the disability application?
YES
NO
Did the condition permanently prevent the member from performing a reasonable range of duties within the
3.
employee’s department?
YES
NO
Did the condition totally prevent the member from performing a reasonable range of duties within the
4.
employee’s department?
YES
NO
Did your review include a medical report describing any conditions or injuries that existed prior to
5.
membership in the pension system? If yes, address in IME report.
YES
NO
Did your review find any pre-existing conditions or injuries that played a role in the disability claimed by the
6.
member? If yes, address in IME report.
YES
NO
7.
Was the injury a result of an event incurred during the performance of the member’s duty detailed above?
YES
NO
8.
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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