CalPERS relies on this report to decide disability and industrial disability retirement. The physician who specializes in the member's disabling condition gives history, findings, diagnoses and an opinion on whether the member is substantially incapacitated from their usual duties, permanently or for at least 12 consecutive months. The physician sends it with medical records straight to CalPERS, or to the employer for Local Safety members.
A physician who specializes in the disabling condition completes Sections 2 through 6. The member's details go in Section 1; for Local Safety members, the employer completes Section 1 and adds its return address before giving the form to the physician.
Page 1 has a box for Local Safety members, police and fire members of contracting agencies. When it is checked, the employer has filled in its name, contact person and address, and the report goes back to that employer with the medical records. For all other members, the report goes to CalPERS. The form warns that every question must be answered or the application is incomplete.
Records the member's name, CalPERS ID or Social Security number, position or occupational title and birth date, plus the medical record number for Kaiser patients. The position title tells the physician which job's duties the incapacity opinion in Section 5 must address.
The physician gives the history of the illness or injury: date of first visit, date of last examination, date the illness or injury occurred and the date the member became unable to perform job duties. Mark the origin as work related or non-work related and describe how the injury occurred, which matters for industrial disability retirement.
Enter the chief complaints and subjective symptoms, along with the member's height, weight and blood pressure. Objective examination findings are recorded in Section 4, paired with each diagnosis and its diagnostic tests and restrictions. The section's printed note again asks for the history of the illness or injury.
For up to two diagnoses, give objective examination findings, diagnostic test dates and findings, and any restrictions or limitations, with comments. Include copies of the medical records and referenced diagnostic test reports. If space runs out, attach a sheet, and label or write the member's Social Security number on every attachment.
After reviewing the duty statement and physical requirements form, answer six questions: whether the member is currently substantially incapacitated from usual duties, listing the specific duties they cannot perform; whether incapacity is permanent or will last at least 12 consecutive months; whether the duty statement, physical requirements form and information from the member or employer were reviewed; and whether medical records are enclosed. Prophylactic restrictions do not qualify.
Indicate whether CalPERS may release a photocopy of the report to the member on written request, then print name, phone, fax and address, and sign with title, medical specialty and date. Send the report to CalPERS, or to the Local Safety employer, and do not give it to the member.
Download the current version from the source each time; forms change without notice.
Physician's Report on Disability
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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A physician who specializes in the member's disabling condition. CalPERS's application guide tells members to give the form to the physician or physicians specializing in the disabling condition, along with the job duty statement and the Physical Requirements of Position/Occupational Title form, so the opinion addresses the member's actual job.
Directly to the CalPERS Disability & Survivor Benefits Division by mail or fax, with copies of the medical records and diagnostic test reports. Do not give it to the member. If the Local Safety member box is checked, return it with the medical reports to the employer named on page 1, which makes the disability determination.
Only if the physician allows it. Section 6 asks whether CalPERS has permission to release a photocopy of the report to the member upon written request, with Yes and No boxes. The physician should not hand the completed report to the member directly.
The member must be substantially unable to perform the usual and customary duties of their position with the current employer, due to a condition expected to last at least 12 consecutive months or to result in death. Disability does not require inability to perform every function, and prophylactic restrictions do not qualify.