Form C4 - Application For Normal Retirement - 2011 Page 9
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22FORM C5-LB-TP
CORRECTIONS OFFICER RETIREMENT PLAN
08/11
3010 E. Camelback Rd., Suite 200, Phoenix, AZ 85016
(602) 255-5575 FAX (602) 296-2369
TOTAL AND PERMANENT
DISABILITY QUESTIONNAIRE
Completed by Local Board and Doctor (if applicable)
LOCAL
Pursuant to A.R.S. §§ 38-881(44) and 38-886, a "Total and Permanent disability” means a physical condition or
mental condition (that is not an accidental disability) that the local board finds totally and permanently prevents a
BOARD
member from engaging in any gainful employment and is in the direct and proximate result of the member's
Initial
performance of the member's duties.
Response
Did the employee file the application after the disabling incident or within one year of ceasing to be an
1.
employee?
YES
NO
Did the employer terminate the member’s employment based on a physical or mental condition that is
2.
being applied for?
YES
NO
3.
Did the employer terminate the employee’s employment based on a disciplinary issue?
YES
NO
Did the member terminate employment based on a physical or mental condition?
4.
YES
NO
5.
Did the member terminate employment based on election to participate in Reverse DROP?
YES
NO
6.
Is the member still working in a job the board believes is gainful employment?
YES
NO
7.
Has the member refused a job the board believes is gainful employment?
YES
NO
8.
Was the condition the direct and proximate result of the member’s duty?
YES
NO
9.
Did the condition or injury occur prior to the member’s membership in the Plan?
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, 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
3.
Does the condition totally prevent the member from engaging in any gainful employment?
YES
NO
4.
Does the condition permanently prevent the member from engaging in any gainful employment?
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 any pre-existing conditions or injuries play a role in the disability claimed by the member? If yes,
6.
address in IME report.
YES
NO
Did your review determine the member may be able to return to work in the next 12 months? If no, address
7.
in the IME report.
YES
NO
8.
Was the condition or injury in the direct and proximate result of the member's performance of their duties?
YES
NO
9.
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
CORRECTIONS OFFICER RETIREMENT PLAN
FORM C5-LB-O
Rev. 07/07/2011
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