MAY 3.

THE NEW ZEALAND GAZETTE.

1855

PHYSICAL EXAMINATION OF CONTRIBUTOR APPLYING TO BE RETIRED AS MEDICALLY UNFIT.

Name of contributor (in full) :
Residence :

1. Employing body, and position held :
2. Age last birthday :
3. Weight and height of contributor: Weight, st. lb.; height, ft. in.
4. Respiration: Is there any disease of the lungs ?
5. Circulation: Is there any disease of the heart or circulatory system ?
6. Digestion: Is there any disease of the stomach, bowels, or liver ?
7. Urinary and genital system: Is there any disease of the kidneys or bladder, or any stricture ? [NOTE.—An analysis of urine should be supplied showing appearance, specific gravity, reaction, and whether there is any albumen, sugar, bile, or deposit.]
   8 Nervous functions—
   (a.) Are there any traces or effects of palsy, convulsion, insanity, or inebriety ?
   (b.) Is there any defect in figure, sight, hearing, or speech ?
   (c.) Has there been any apoplexy ?
8. Surface: Is there any otorrhœa ?
9. Is there any circumstance relating to the personal constitution or health, or habits, &c., of the contributor not above specified, but known or suspected by you, that should, in your opinion, be disclosed to the Superannuation Board ?
10. If the contributor is in bad health, do you think his habits of life, past or present, especially in reference to the use of intoxicating liquor, have in any way conduced to his present condition ? [NOTE.—The Medical Examiner will be expected to answer this question fully, as the Superannuation Board requires to be satisfied that the contributor’s condition has not been caused by irregular or intemperate habits.]

CERTIFICATE.

I do hereby certify that I have this day of , 19 , made a careful physical examination of , and that the queries above have been answered by me to the best of my knowledge and judgment; and, after careful consideration of the whole evidence before me, I am of opinion that his condition and health are [NOTE.—The Medical Examiner will here give a full description of the contributor’s condition and health, and should state his opinion as to whether the contributor is permanently unable to perform his duties].

Given under my hand, at , this day of , 19 .
[Signature.]

RECOMMENDATION of Chief Health Officer.
[Signature.]
[Date.]

21. The reports of the medical practitioners referred to in the last preceding clause shall be submitted to the Chief Health Officer for his recommendation thereon, and shall not be considered by the Board without such recommendation.

22. In the case of the re-examination of a contributor in receipt of an allowance as “medically unfit,” the Board may prescribe a modified form of report in substitution for that prescribed in clause 20 hereof. In all such cases of re-examination any report to the Board recommending that no further examination is necessary shall be confirmed by the Chief Health Officer.

23. The members of the Board shall, at the first quarterly meeting after the triennial election of members representing the contributors to the Fund, elect a committee of three members, of which two shall form a quorum, to consider in detail and to report to the Board on all applications for retirement under the extended provisions of section 12 of the Act as amended by section 11 of the Public Service Classification and Superannuation Amendment Act, 1909. The committee shall report as to whether any such application should be granted, and, if so, as to what terms of payment to the Fund or reduction in the allowance should be imposed on the retiring contributor. When necessary the committee shall consult with the Actuary of the Government Life Insurance Department regarding the terms on which the retirement should be granted.

24. The committee referred to in the last preceding clause shall also consider and report to the Board on all applications for retirement on the grounds of medical unfitness for further duty, and also on all annuitants retired as being medically unfit who have been re-examined, or who, in the opinion of the committee, should be re-examined.

25. The Director of Education (if and so long as he is a member of the Board) shall act as a committee of the Board to consider all claims for benefits from the Fund not dealt with by the committee referred to in the two last preceding clauses.

26. The Board shall, at its first meeting after receipt of the necessary particulars, consider such cases as have been reported upon, and grant allowances in accordance with the terms of the Act, and determine the date from which the payment in each case shall be made.

27. Allowances granted to widows and children shall be due and payable on the last day of each month, and, except as to the first and last instalment, shall be in equal monthly instalments of £1 10s. for a widow and £1 1s. 8d. for each child.