APPLICATION FOR ILL HEALTH / DISABILITY RETIREMENT

Transcription

1 Page 1 of 17 SECTION 1A: MEMBER S GENERAL DETAILS To be completed by the member 1. Title: 2. First names and surname: 3. Start date of employment: Y Y Y Y M M D D 4. ID / smart card / passport number: 5. Qualifications: 6. Division / business unit: 7. Department / section: 8. Name of physical workplace: 9. Current designation / accommodated position if any: 10. Contact details: Residential address: Postal address: Postal code: Home telephone number: Work telephone number: address: Postal code: Cell phone number: Fax number: 11. Occupational history: Date from Date to Organisation Occupation 12. Married Yes No Children Yes No Dependants Yes No 13. Own home Yes No Rental Yes No Number of dependants 14. Hobbies: 15. Sport activities: 16. I confirm that I am fully aware of this application: Yes No 17. This application was initiated by: Self Employer Medical

2 Page 2 of 17 SECTION 1B MEMBER S CLINICAL HISTORY To be completed by the member 1. What is the cause of your disability? 2. Describe fully the nature of your disability: 3. In your opinion, is your disability permanent? Yes No 4. Date of first symptoms and / or accidental injury relating to your disability: 5. Name and address of first doctor you consulted in connection with your symptoms or injury: 6. Did you consult or were you referred to any other doctor / specialist / hospital? Yes No If yes, state: Name Date Address 7. Are you currently under treatment? Yes No If yes, state doctor / specialist / hospital s name and address: 8. Describe what treatment you have received for this disability and the result of such treatment: 9. Is any further treatment or operation contemplated? Yes No If yes, state nature and date: Nature of treatment or operation Doctor / hospital s name Date

3 Page 3 of 17 SECTION 1B Continued MEMBER S CLINICAL HISTORY To be completed by the member 10. Are you confined to: Bed Yes No House Yes No Wheelchair Yes No Any other life activity restrictions? 11. Which of your occupational activities are you unable to perform efficiently? 12. Which of your occupational activities can you perform efficiently? 13. Have your occupational activities / post ever been adjusted to accommodate your impairment? If yes, please provide details: 14. Do you have any suggestions about changes to your occupational activities in order to Yes No accommodate your impairment? If yes, please provide details: 15. On what date were you last able to undertake any part of your occupational duties? 16. Will you, in future, be able to resume your occupation in whole or in part? Yes No If no, state what type of similar or other occupation you are likely to be able to follow, taking into consideration your experience, knowledge, training and abilities, if any: 17. When are you likely to be able to commence such similar or other occupation? 18. What other types of occupations have you followed in the past? Yes

4 Page 4 of 17 SECTION 1B Continued MEMBER S CLINICAL HISTORY To be completed by the member Please Note: The questions posed in this form are specifically designed to provide the member with an opportunity to present information to the EPPF to properly evaluate this application. Should you wish to do so, you may provide any additional information / motivation, in the space below or by attaching a separate document. 19. Member s additional information/motivation:

5 Page 5 of 17 SECTION 1C MEMBER S DECLARATION To be completed by the member PLEASE READ THE FOLLOWING DECLARATION CAREFULLY, BEFORE SIGNING AT THE PLACE PROVIDED FOR YOUR SIGNATURE. 1. I, the undersigned, hereby apply for the granting of ill-health / disability retirement in terms of the EPPF rules. 2. I acknowledge and understand that my duty to disclose all relevant information includes the disclosure of all and any information pertaining to my health and previous medical history to enable my application for ill health / disability retirement to be properly assessed. 3. I declare and undertake that all the information and details I will furnish to my employer or any examining medical doctor / practitioner / specialist in supporting my application for ill health retirement will be true and accurate to the best of my knowledge. I declare and undertake that no medical or other information, which would reasonably be required by my employer or the EPPF to consider and assess my application for ill health retirement, will be deliberately withheld, omitted or concealed. 4. I hereby authorise my employer and the EPPF irrevocably to obtain any information that they in their sole discretion might consider necessary in respect of my health and employment circumstances from any person who has such information available and I hereby indemnify anybody who, at the request of the above-mentioned provides information against any legal action whatsoever as a result of them providing such information. 5. I agree and consent to any necessary or appropriate medical or other investigations concerning medical information or details I will provide, or have already provided or which may be or become required. I am aware that the EPPF may require medical practitioners / specialists to undertake full medical examinations of me, and I confirm my willingness to co-operate and participate in any medical or related examinations, which may be considered necessary. 6. I hereby authorise, consent to and instruct any doctor / hospital / clinic / institution / specialist / similar person / body, which is presently or may be in possession of (or may in future come into possession of) any information or knowledge concerning my past, present or future state of health, to disclose and make these available to my employer or the EPPF. I further declare that this authorisation, consent and instruction must remain valid before, as well as after, my death, should this occur. 7. I hereby indemnify my employer and the EPPF, their employees and any medical officer designated by them for medical examination purposes, against any claims flowing forth from any such medical examinations, reports and recommendations and the consequences thereof. 8. I hereby acknowledge that I can apply for early retirement during the first five years of membership on the basis of ill health / disability. However, in the event that the condition which has resulted in my inability to continue working for my employer is related to any injury or illness that had occurred prior to commencement of membership, or was known to me during the six months prior to commencement of membership, the benefit shall be reduced in terms of the EPPF rules. 9. I hereby acknowledge that I understand that the wilful supply of false, inaccurate or incomplete information and / or detail supplied in support of my application for ill health retirement, can lead to EPPF declining this application or pursuing legal options. Initial in block SIGNED ON THIS DAY OF 20 AT MEMBER S SIGNATURE: WITNESS 1: WITNESS 2:

6 Page 6 of 17 SECTION 1D MEDICAL REPORT FROM MEMBER S OWN MEDICAL PRACTITIONER / SPECIALIST Please Note: In terms of Rule 25(4)(a) the EPPF shall make its decision after considering such medical evidence as to the state of the member s health as may be supplied to the EPPF. The member s own medical practitioner / specialist is therefore requested to provide the EPPF with the necessary information regarding the member s state of health by completing the questions posed below and by attaching to this document any additional reports / results of special investigations as to enable the EPPF to properly consider this application. Note that this section is not a replacement for a full comprehensive medical report. 1. State date on which you were first consulted by the member in connection with this impairment? _ 2. Is the member still under your care? Yes No Not regularly 3. What date was the member last attended to by you? 4. What is the medical diagnosis made by you? _ 5. What is the cause of the member s medical impairment? _ 6. What is the prognosis of the member s impairment? 7. Describe the treatment and response to the treatment: _ 8. State details of any further treatment or operations contemplated: 9. Is the clinical condition stabilised? Yes No If no, please motivate:

7 Page 7 of 17 SECTION 1D continued MEDICAL REPORT FROM MEMBER S OWN MEDICAL PRACTITIONER / SPECIALIST 11. Briefly explain the impact of the medical impairment on the member s capability to perform the following activities, by stating Yes if the member is capable of performing the activity and by stating No if the member is not capable of performing the listed activity. Self care personal hygiene Bathing Yes No Grooming Yes No Dressing Yes No Eating Yes No Physical activities Reclining Yes No Exercising Yes No Sensory Function Feeling (touch) Yes No Smelling Yes No Hand functions Grasping Yes No Holding Yes No Pinching Yes No Percussion movements Yes No Sensory discrimination Yes No Travel Riding Yes No Driving Yes No Travelling by aeroplane Yes No Travelling by train Yes No Travelling by car Yes No Sleep Having a restful sleep pattern Yes No Social and recreation activities Partake in individual activities Yes No Partake in any form of sport Yes No Practising any hobbies Yes No 12. In the above categories, please motivate the No answers, except in the Social recreation activities category: _

8 Page 8 of 17 SECTION 1D continued MEDICAL REPORT FROM MEMBER S OWN MEDICAL PRACTITIONER / SPECIALIST 13. Indicate by marking the relevant criteria which the member is able to occupation: Working activities Sitting Yes No Bending Yes No Walking Yes No Kneeling Yes No Balancing Yes No Pulling Yes No Squatting Yes No Twisting Yes No Use of right hand Yes No Use of left hand Yes No Use of right foot Yes No Use if left foot Yes No Reading Yes No Writing Yes No Hearing Yes No Standing Yes No Crawling Yes No Carrying Yes No Climbing Yes No Pushing Yes No Lifting Yes No Reaching Yes No Learning Yes No Vision: Distance Yes No Vision: Near work Yes No Vision: Colour Yes No Vision: Night vision Yes No Vision: Depth perception Yes No Speech Yes No Wearing of protective clothing Eye protection Yes No Hearing protection Yes No Safety belt Yes No Protective overalls Yes No Hand gloves Yes No Respirator Yes No Foot protection Yes No Use of hard hat Yes No

9 Page 9 of 17 SECTION 1D continued MEDICAL REPORT FROM MEMBER S OWN MEDICAL PRACTITIONER / SPECIALIST Travelling Driving a car Yes No Psych-social Can the member work under mental stress Yes No Airborne environment Can the member perform work activities in any of the listed environments? Chemical environment Can the member perform work activities in any of the listed environments? Asbestos Yes No Fumes Yes No Vapours Yes No Dust Yes No Gases Yes No Hazardous substances Yes No Lead Yes No Solvents Yes No Pesticides Organic PCB s Yes No PAH Yes No 14. State in your opinion whether any of the following measures would assist the member to carry out usual activities to meet personal, social and occupational demands: Restrictions Yes No Accommodation Yes No Therapeutic intervention Yes No Rehabilitation programme Yes No Support devices Yes No Please motivate if answered Yes to any of the above-mentioned questions: 15. Please state whether the medical interventions, treatment and operations performed by you on the member were successful, partially successful or unsuccessful: Successful Partially successful Unsuccessful If partially successful or unsuccessful, please state the reason:

10 Page 10 of 17 SECTION 1D continued MEDICAL REPORT FROM MEMBER S OWN MEDICAL PRACTITIONER / SPECIALIST 16. Based on your medical evaluation and prognosis, please state whether the member s impairment is of a permanent nature or not: Permanent Not permanent If you answered Not permanent, please give reasons: 17. In your medical opinion, would the member be able to perform any other occupation in the open labour market? Yes No If yes, please state suggested type of occupation: If no, please provide reasons: Note: The absence of supporting medical reports / documents would cause this application to be rejected. I hereby confirm that: I have confirmed the identity of the person that I have examined to be the member whose application this is. I have attached all relevant medical reports and special investigations. Medical Examiner s Initials & surname (Please print): Medical Examiners Signature: Qualifications: Practice number: Address: Telephone number: Fax number: Date: address: MEDICAL EXAMINER S OFFICIAL STAMP

11 Page 11 of 17 SECTION 2A PHYSICAL JOB SPECIFICATIONS To be completed by the member s direct supervisor / manager SHORT DESCRIPTION OF KEY WORK ACTIVITIES AND CRITICAL TASKS % TIME LIST IDENTIFIED CHEMICAL HAZARDS AND POTENTIAL HAZARDOUS OCCUPATIONAL EXPOSURE LIMITS PHYSICAL HAZARDS WORK ENVIRONMENT AND ACTIVITY HAZARDS 1. Thermal environment Hot Cold N/A 2. Noise dB >105dB N/A 3. Vibration Yes No 4. Illumination Yes No 5. Electrical contact Yes No 6. Direct physical ergonomic stressors: - Rough terrain Yes No - Repetitive strain Yes No - Strenuous physical work Yes No - Climbing Yes No - Driving / travelling Yes No - Heights Yes No - Confined spaces / crouching position Yes No - Other: RADIATION 1. Ionising <5mSv >5mSv N/A 2.. Non Ionising: - Ultra violet Yes No - EMF Yes No 3. Other: CHEMICAL (List above) 1. Hazardous chemical substances Yes No 2. Hazardous biological substances Yes No 3. Other:

12 Page 12 of 17 SECTION 2A PHYSICAL JOB SPECIFICATION To be completed by the member s direct Supervisor / Manager PSYCHO-SOCIAL STRESSORS 1. Shift work Yes No 2. Mental alertness Yes No 3. Extended period away from home Yes No REQUIRED PHYSICAL ATTRIBUTES FOR WORK PERFORMANCE Rating to be used: 1 = Not important 2 = Important 3 = Essential 1. Hearing 2. Visual activity 3. Colour vision 4. Depth perception 5. Eye/hand/feet coordination 6. Fine motor skills 7. Balance 8. Physical strength 9. Stamina 10. Mobility/agility 11. Heat tolerance 12. Working at heights 13. Working in confined spaces 14. Clear speech 15. Communication skills 16. Other PERSONAL PROTECTIVE EQUIPMENT REQUIRED FOR JOB 1. Hard hat 2. Respirator 3. Hearing protection 4. Safety boots 5. Goggles 6. Overall 7. Dust mask 8. Rainwear 9. Apron Spats 10. Face shield 11. SCBA 12. Other

13 Page 13 of 17 SECTION 2B SUPERVISOR S MOTIVATION IN RESPECT OF APPLICATION 1. Please state member s last four performance ratings: Last 2 nd Last 3 rd Last 4 th Last Appraisal Rating Appraisal Date 2. Please state any specific outputs for training or retaining set in the member s personal development plan: 3. Please indicate which steps, if any, have been taken to adapt the member s work outputs to accommodate his / her impairment? 4. Please indicate whether the member has previously been re-deployed into an alternative job to accommodate his / her impairment: Yes No If yes, please provide details / results: 5. Please indicate whether the member has been classified as a person with a disability as defined by the Employment Equity Act: Yes No If yes, please provide details of accommodations made:

14 Page 14 of 17 SECTION 2B Continued SUPERVISOR S MOTIVATION IN RESPECT OF APPLICATION Please Note The questions posed in this form are specifically designed to provide the member with an opportunity to present information to the EPPF as to properly evaluate this application. Should the employer wishes to bring / provide any additional information to the attention of the EPPF, the employer has an opportunity to provide any such additional information / motivation, in the space below or by attaching a separate document. 6. Please provide any additional information / motivation that you feel is appropriate which was not covered in the questions posed above: 7. Supervisor s name: 8. Supervisor s address: 9. Supervisor s designation: 10. Work telephone number: 11. Work fax number: 12. Supervisor s signature: Date:

15 Page 15 of 17 SECTION 2C MEMBER S SICK LEAVE RECORD To be completed by the Human Resources Practitioner 1. Amount of sick leave used by member over the last 36 months: 2. Balance of sick leave available to the member on (date): 3. Member s Sick Absenteeism (SAR) Rate: Formula to calculate Sick Absenteeism Rate (SAR): Total sick leave days of member for the last 36 months x 100 Note: Mondays = average days per month (22) Total potential Mondays for the same period SECTION D2 MEMBER S DETAILED OCCUPATIONAL AND TRAINING / EDUCATIONAL HISTORY To be completed by the Human Resources Practitioner 1. Please provide a detailed occupational history of the member whilst employed in Eskom or any other employers participating in the EPPF: Date from Date to Business unit Designation 2. Please attach a detailed copy of the member s training record.

16 Page 16 of 17 SECTION 2E CHECKLIST To be completed by the Human Resources Practitioner All items must be signed off by the responsible HR Functionary before sending the application to the Occupational Health Nursing Practitioner 1. I confirm that Sections 1A to 1C of this form have been completed by the: member or the employer or person acting on behalf of the member 2. I confirm that a copy of the member s ID./ smart card / passport is attached to this application 3. I confirm that Section 1D of this form has been completed and all relevant reports are attached Note: Section 1D is not considered to be a full comprehensive medical report. Section 1D should therefore be completed as well as medical reports attached to this application as supporting documentation. Section 2F: This is confidential medical information. 4. I confirm that Sections 2A to 2E of this form have been completed 5. I confirm that Sections 2A to 2E of this form have been completed 6. Details of the employee (practitioner) in the Human Resources Department who completed the checklist: First name and surname: Designation: Signature: Place of work: Unique number: Region / division: Employer: Postal address: Work telephone number: Fax number: address: Date: 7. Forward this form and supporting documentation to the Occupational Health Nursing Practitioner.

17 Page 17 of 17 SECTION 2E CHECKLIST To be completed by the Occupational Health Nursing Practitioner 1. I confirm that a medical report from a medical specialist nominated by the applicant is attached Note: Section 1D is not considered to be a full comprehensive medical report. Section 1D should therefore be completed as well as medical reports attached to this application as supporting documentation. 2. I confirm that the Eskom Occupational Medical Practitioner s original medical report is attached. 3. I confirm that the pre-employment surveillance form is attached (applicable to employees with less than five years of service). 4. I confirm that the attached medical reports from treating doctors and specialists include medical reports that are not older than six months. 5. Details of the Occupational Health Nursing Practitioner: First name and surname: Unique number: Place of work: Region / division: Group: Postal address: Work telephone number: Fax number: address: Signature: Date: 6. Forward all documentation to: The Secretariat Eskom Medical Panel MWP Clinic Megawatt Park Maxwell Drive Sunninghill SANDTON 2157 Telephone number: Fax number: address: Annelie.dPlessis@eskom.co.za