A. CHECK NUMBER OF HOURS A DAY:
DESCRIBE THE KIND AND AMOUNT OF PHYSICAL ACTIVITY THIS JOB INVOLVED DURING A TYPICAL DAY IN TERMS OF:
Position Description Attached
NAME OF SUPERVISOR (PLEASE PRINT)
Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800, or cs@retirement.sc.gov
Return completed form to the SC Retirement Systems (address above).
DESCRIBE BASIC DUTIES OF JOB BELOW AND ATTACH EMPLOYEE'S POSITION DESCRIPTION.
ALSO, EXPLAIN ALL "YES" ANSWERS ABOVE BY GIVING A FULL DESCRIPTION OF:
A. Type of machines, tools, or equipment used, and exact operations performed.
B. The technical knowledge or skills involved.
C. Type of writing done and nature of reports.
D. The number of people supervised and the extent of supervision.
DISABILITY APPLICANT/EMPLOYEE INFORMATION
The individual indicated below has applied for disability retirement benefits. Please complete the information on the remainder of this form, and return it to the address listed above as soon as possible. Upon receipt of this completed form, the employee's application will be processed.
EMPLOYER'S DESCRIPTION OF DISABILITY APPLICANT'S JOB
(TO BE COMPLETED BY APPLICANT'S SUPERVISOR)
SC Public Employee Benefit Authority
South Carolina Retirement Systems
ATTENTION: CUSTOMER ANNUITY CLAIMS
PO Box 11960, Columbia SC 29211-1960
Form 6254
Revised 7/9/2012
Print or type in black ink
Date employee started this position:
Date employee stopped work in this position because of disability:
3. Social Security Number
1. Use machines, tools, or equipment of any kind?
2. Use technical knowledge of any kind?
3. Do any writing, complete reports, or perform similar duties?
4. Have supervisory responsibilities?
IN THIS JOB DID THE EMPLOYEE:
THIS EMPLOYEE FREQUENTLY (1/3 TO 2/3 OF AN 8-HOUR DAY) LIFTS AND/OR CARRIES:
THIS EMPLOYEE OCCASIONALLY (UP TO 1/3 OF AN 8-HOUR DAY) LIFTS AND/OR CARRIES:
HANDLE, GRAB, OR GRASP LARGE OBJECTS
WRITE, TYPE, OR HANDLE SMALL OBJECTS