Ill Health Retirement Application Form - Pensions

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GUS9 ISLE OF MAN GOVERNMENT UNIFIED SCHEMEDEFERRED ILL HEALTH RETIREMENT APPLICATION FORMPart DTo be completed by the Occupational <strong>Health</strong> Doctor.Where this is not possible, a GP or specialist can provide a medical report.It is recommended that before a doctor considers completing this form, they read Section 1 –Understanding ill health retirement and the application process on pages 1 to 4 of this form.Medical informationD1. Please list all currently diagnosed medical conditions giving date of onset for each.D2. Provide details of the report reason(s) for current incapacity.D3. Please provide details of the past course of any medical conditions currently reported asgiving rise to incapacity.12
GUS9 ISLE OF MAN GOVERNMENT UNIFIED SCHEMEDEFERRED ILL HEALTH RETIREMENT APPLICATION FORMD4. Please provide details of reported symptoms, objective clinical findings, investigationfindings, reported functional impairment and objectively confirmed functional impairment.D5. Please describe all relevant (to currently incapacitating conditions) therapeutic interventionto date giving details of the nature of treatments, dates, durations, compliance, response andany adverse effects.D6. What is the likely future course of this member’s health and function, with normaltherapeutic intervention, over the period to age 65?13
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Ill Health Retirement Application Form - Pensions

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