PWGSC-TPSGC 2012: Interpretation of medical examination for pension purposes

Privacy notice

Provision of the information requested on this document is required under paragraphs 13(1)(b) and (d) and section 28 of the Public Service Superannuation Act (PSSA) and sections 42.1, 43.2 and 43.3 of the PSSA Regulations. The information will be used for the purpose of determining entitlement to a pension for medical reason. The personal information is described in Personal Information Banks PWGSC PCE 702 and HCan PCE 701/703, and will only be used and disclosed in accordance with the provisions of the Privacy Act. Under this act, the individual to whom the information pertains has the right to request access to and correction of the personal information, if erroneous or incomplete. The records will be retained by the department for two years following the last administrative action, and then destroyed.

Read instructions before completing

The plan member must complete Sections A and B.
The plan member may seek assistance from his compensation advisor or the designated person in his organization to complete Section A and obtain a copy of his work description (Duties and Requirements of Position) which must be attached and sent with the form.
On page 1, the plan member must provide either his PRI or his Pension Number. The pension administration only requires one of the two to identify the account.
Only indicate the Termination Date, if it is known.
This form, along with the Occupational Health Assessment Report (HC-SC 3312) must be sent to the Medical Services Branch office indicated in Section C.
Please contact the Public Service Pension Centre to obtain the HC-SC 3312E form.

Definitions

A plan member is disabled if he is suffering from a physical or mental impairment that:
1. prevents him from engaging in any employment for which he is reasonably suited by virtue of his education, training or experience; and
2. can reasonably be expected to last for the remainder of his lifetime.
A plan member is disabled if incapable of pursuing regularly any substantially gainful occupation.
In considering what constitutes "substantially gainful occupation", the impairment must prevent the plan member from engaging in employment commensurate with his education, training and experience.

Note

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Instructions for fillable PDF forms

Plan member's personal information

Surname

Plan Member's Personal Information PRI

Given Names

Pension No.

Date of Birth (YYYYMMDD)

Preferred Language

English French

Preferred Telephone No.

Home Address

Apartment No.

City

Province

Postal Code

Country

Email Address (optional)

A. General information (to be completed by the plan member)

Type of application (check the applicable box)

First Review

Re-examination where disability commenced before January 1, 1996

Department, Board, Commission or Corporation, etc.

Address (include postal code)

Classification or Position Title

Duties and Requirements of Position
(Please attach a copy of your work description)

Termination Date (Y-M-D)

B. Declaration of plan member

I understand that this application is initiated for medical retirement.

A copy of my work description is attached.

Signature of Plan Member

Date (Y-M-D)

C. Examining physician

C. Examining Physician Instructions

The details of the medical examination should be entered on form HC/SC 3312E. Forms PWGSC-TPSGC 2012 and HC/SC 3312E should then be sent to the appropriate Medical Services Branch office, located at:

C. Examining Physician Address

Note 1:

Please do not send form HC/SC 3312E or confidential medical information to any non-medical government office.

Declaration

I, the undersigned, duly qualified medical practitioner, certify that I have made a detailed examination of the above-named plan member and that in my opinion the said individual:

(Check one box only)

is capable of pursuing regularly the duties of his position, or any substantially gainful occupation

is temporarily incapable of pursuing regularly any substantially gainful occupation; however, it is estimated that he might be able to return to work in

Examine Date Date
(months and years)

is permanently incapable of pursuing regularly any substantially gainful occupation commencing

Declaration Date (Y-M-D)

Signature of Physician

DeclarationDate (Y-M-D)

Address and Tel. No.

D. Health Canada

Note to Medical Services Branch:

The original of form PWGSC-TPSGC 2012 should be forwarded to the Public Service Pension Centre - Mail Facility, 150 Dion Blvd, PO Box 8000, Matane QC G4W 4T6. Complete number 1 or 2 below.

A copy of the completed form should be sent to the employer indicated in Section A.

1. Recommendation of Health Canada

Where disability commenced on or after January 1, 1996 (refer to definition 1 under instructions)

Retirement on the grounds of permanent disability is recommended effective

Recommendation 1Date (Y-M-D)

Retirement on the grounds of disability is not recommended

or

2. Recommendation of Health Canada

Where disability commenced before January 1, 1996 (refer to definition 2 under instructions)

Retirement on the grounds of permanent disability was recommended effective

Recommendation 2 Date (Y-M-D)

Recommendation 2 Retirement on the grounds of disability was recommended effective

Recommendation 3 Date (Y-M-D)

and a medical review is to be conducted in
(months and years)

Retirement on the grounds of disability is not recommended

Health regained

For Assistant Deputy Minister, Health Canada

Assistant Deputy MinisterDate (Y-M-D)

For office use only

Form No.

Case No.

PRI

For Office Use Only Pension No.

PWGSC-TPSGC 2012 (12/2009)

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