Kentucky teachers applying for a disability retirement annuity, and disability retirees under review, need their physician to complete this two-page evaluation. It records the history, a physical exam done within the last three months, diagnosis, how the condition affects job duties, treatment, and the physician's conclusion on disability, and TRS uses it to apply the eligibility test that fits the member's situation.
The member's physician completes the whole form, items 1 through 9 and the Physician's Conclusion, and attaches reports from examinations related to the disabling condition. The member applies separately for the disability retirement annuity.
Download the current version from the source each time; forms change without notice.
Physician's Disability Evaluation Report
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The examination date entered at the top must be within the last three months. The physician should attach reports, statements and other information from examinations performed in relation to the disabling physical or mental condition, since TRS returns incomplete forms.
After the diagnosis, functional impact, treatment and rehabilitation questions, the physician certifies whether the member is physically or mentally disabled or not disabled, then signs and dates the form and adds a printed name, type of specialist if applicable, and practice contact details.
No. Form D-3 belongs to the Teachers' Retirement System of the State of Kentucky. The Kentucky Public Pensions Authority, which runs KERS, CERS and SPRS, has no treating-physician form; its members submit records with Form 8001 for review by KPPA medical examiners.