Canada / Czech Republic Agreement

Transkript

1 Canada / Czech Republic Agreement Applying for Czech Benefits Here is some important information you need to consider when completing your application. Please ensure you sign the application. If you are signing with a mark, (for example: X ) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Commissioner of Oaths; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioner: Chiropractor, Dentist, Doctor, Naturopathic Doctor, Nurse Practitioner, Ophthalmologist, Optometrist, Pharmacist, Psychologist, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Official of a country with which Canada has a reciprocal social security agreement; Police Officer; Professional Engineer; Social Worker; Teacher, University Professor. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to: International Operations Service Canada P.O. Box 2710 Station Main Edmonton, AB T5J 2G4 CANADA

2 Disclaimer: This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources.

3 CAN-CZ 1 SMLOUVA O SOCIÁLNÍM ZABEZPE ENÍ MEZI ESKOU REPUBLIKOU A KANADOU ZE DNE AGREEMENT ON SOCIAL SECURITY BETWEEN THE CZECH REPUBLIC AND CANADA OF 24 th MAY 2001 ŽÁDOST O D CHOD Z ESKÉ REPUBLIKY CLAIM FOR A PENSION FROM THE CZECH REPUBLIC lánky 11, 12 a 13 Smlouvy, ást 4 Správního ujednání Articles 11, 12 and 13 of the Agreement, Section 4 of the Administrative Arrangement Žádost o / Claim for: starobní d chod / an old-age pension invalidní d chod / an invalidity pension poz stalostní d chod / a survivor s pension Vyplní kanadská instituce sociálního zabezpe ení / It will be filled in by the Canadian Social Security Institution Datum p ijetí žádosti / Filing date of this application: Razítko / Stamp: nujte, prosím, pozornost Poznámkám na poslední stran, kde jsou uvedeny informace a instrukce, jak vyplnit tuto žádost. Please refer to the Notes on the last page for more information and instructions on how to complete this claim form. 1 Žadatel(ka) / Applicant 1.1 P íjmení / Last name Rodné a všechna další p íjmení 1) / Last name at birth and all other last names 1) 1.2 Jméno / First name 1.3 Datum narození / Date of birth: Den / Day síc / Month Rok / Year Místo narození / Place of birth 1.4 Identifika ní íslo íslo pojišt ní / Identification number Insurance number v Kanad (kanadské íslo sociálního pojišt ní) / in Canada (Canadian Social Insurance Number) v eské republice (rodné íslo) 2) / In the Czech Republic (Birth number) 2) 1.5 Pohlaví / Sex: Muž / Male Žena / Female 1.6 Státní p íslušnost / Nationality 1.7 Rodinný stav / Marital status: svobodný(á) / single ženatý/vdaná / married rozvedený(á) / divorced vdovec/vdova / widower/widow 1.8 Adresa / Address Adresa posledního trvalého pobytu na území eské republiky (bývalého eskoslovenska) / Last address in the Czech Republic (former Czechoslovakia) 1.11 Pobírám d chod / I have been receiving pension payments - jaký druh / type of pension - od koho (název instituce) / paid by (name of the agency) - pod íslem / reference number Nepobírám d chod / I have not been receiving pension payments 1

4 CAN-CZ 1 2 Body 2.1 až 2.13 se vypl ují pouze u žádosti o poz stalostní d chod / Points to be completed only by applicants for a survivor s pension V bodech uve te, prosím, podrobnosti o zem elém manželovi/manželce nebo rodi i / Please provide details of deceased spouse or parent in Points P íjmení / Last name Rodné a všechna další p íjmení 1) / Last name at birth and all other last names 1) 2.2 Jméno / First name 2.3 Datum narození / Date of birth: Den / Day síc / Month Rok / Year Místo narození / Place of birth 2.4 Datum úmrtí / Date of death: Den / Day síc / Month Rok / Year Místo úmrtí / Place of death 2.5 Identifika ní íslo íslo pojišt ní zem elého / Identification number Insurance number of the deceased person v Kanad (kanadské íslo sociálního pojišt ní) / in Canada (Canadian Social Insurance Number) v eské republice (rodné íslo) 2) / In the Czech Republic (Birth number) 2) 2.6 Pohlaví / Sex: Muž / Male Žena / Female 2.7 Státní p íslušnost / Nationality 2.8 Adresa ke dni úmrtí / Address as of the date of death 2.9 Adresa posledního trvalého pobytu zem elé(ho) na území eské republiky (bývalého eskoslovenska) / Last address of the deceased person in the Czech Republic (former Czechoslovakia) 2.10 Zem elý(á) pobíral(a) d chod / Deceased person had been receiving pension payments - jaký druh / type of pension - od koho (název instituce) / paid by (name of the agency) - pod íslem / reference number Zem elý(á) nepobíral(a) d chod / Deceased person had not been receiving pension payments Pokud byla zem elá osoba manželem/manželkou žadatele(ky), odpov zte na otázky v bodech 2.11 a 2.12 / If the deceased person was the applicant s spouse, complete Questions 2.11 and Trvalo manželství žadatele se zesnulou osobou ke dni úmrtí? Were the applicant and the deceased person married as of the date of death? ano / yes ne / no 2.12 Uzav el(a) žadatel(ka) po úmrtí osoby uvedené v bod 2.1 nový s atek? / Has the applicant remarried after the death of the person mentioned in 2.1? ano / yes, datum nového s atku / date of the new marriage: Den / Day síc / Month Rok / Year ne / no 2

5 CAN-CZ 1 Pokud byla zem elá osoba rodi em žadatele(ky), vypl te bod 2.13 / If the deceased person was the applicant s parent, complete Question Žádost o p iznání sirot ího d chodu 3) Application for orphan s pension 3) Jméno a p íjmení dít te First name and last name of child Rodné íslo v R 2) Czech Birth Certificate Number 2) Datum narození (D/M/R) Date of birth (D/M/Y) Jméno a p íjmení otce dít te First name and last name of child s father Jméno a p íjmení matky dít te First name and last name of child s mother Pobírá-li dít chod, uve te jaký a název instituce, která jej vyplácí If the child has been receiving a pension, please specify its type and name of paying agency Zam stnání a historie pojišt ní / Employment and Insurance History 3 Žadatel(ka) poskytne podrobnosti o svých dobách pojišt ní a/nebo dobách zam stnání Upozorn ní: V p ípad žádosti o poz stalostní d chod, žadatel(ka) uvede pouze doby pojišt ní a/nebo zam stnání zem elé osoby. Applicant must provide details of his/her periods of insurance and/or periods of employment Note: If this application is for a survivor s pension, the applicant must state periods of insurance and/or periods of employment of the deceased person only. Od (D/M/R) From (D/M/Y) Do (D/M/R) To (D/M/Y) ehled o dobách zam stnání, pojišt ní a o náhradních dobách pojišt ní od ukon ení povinné školní docházky až do dne podání žádosti o d chod List of employment, insurance periods and substitute insurance periods from the date of completing compulsory education until the date of submission of this application Stát 4) Country 4) edkládá se doklad Documents submitted Studium, u ení Studies, apprenticeship Vojenská služba civilní služba vojenské cvi ení Military Service civilian service military exercise Odbojová innost (osv ení dle zákona. 255/1946 Sb.) 5) ano / yes ne / no Participation in the Resistance (Certificate as per Act 255/1946 Coll.) 5) 3

6 CAN-CZ 1 Od (D/M/R) From (D/M/Y) Do (D/M/R) To (D/M/Y) ehled o dobách zam stnání, pojišt ní a o náhradních dobách pojišt ní od ukon ení povinné školní docházky až do dne podání žádosti o d chod List of employment, insurance periods and substitute insurance periods from the date of completing compulsory education until the date of submission of this application Stát 4) Country 4) edkládá se doklad Documents submitted Doba pojišt ní zam stnání Insurance periods Employment periods Název podniku Adresa pracovišt Name of company Address of workplace Druh pracovn právního, p íp. jiného vztahu Type of employment or similar relationship 4 Prohlášení o dob pé e o d ti výchov d tí / Declaration of periods of child care child rearing Jméno a p íjmení dít te First name and last name of child Datum narození Date of birth (D/M/R-D/M/Y) Jméno a p íjmení otce dít te First name and last name of child s father Jméno a p íjmení matky dít te First name and last name of child s mother Doba osobní pé e o d ti Period of personal care for children Od / from (D/M/R-D/M/Y) Do / to (D/M/R-D/M/Y) Je-li dít nebo bylo-li dít v zaopat ení jiné osoby nebo ústavu, uve te kde a jak dlouho (od kdy-do kdy) / If the child is or was cared for by another person or institution, indicate where and how long (from-to) 4

7 CAN-CZ 1 5 Prohlášení o zam stnání nebo samostatné výd le né innosti žadatele(ky) / Applicant s employment or self-employment declaration Prohlašuji, že moje zam stnání nebo samostatná výd le ná innost / I declare that my employment or self-employment: skon ila (skon í) dne / ended (will end) on: Den / Day síc / Month Rok / Year trvá / still continues 6 Vypl uje se pouze u žádosti o starobní d chod / To be completed only by applicants for an old-age pension Žádám, aby starobní d chod byl p iznán: / I claim for an old-age pension: ode dne vzniku nároku / as of the date of entitlement od jiného data / as of another date: Den / Day síc / Month Rok / Year 7 Zp sob výplaty d chodu / Method of pension payment Žádám, aby mi byl d chod vyplácen / Please pay my pension: na m j ú et / into my bank account: - název ú tu / account name íslo ú tu / account number - mezinárodní íslo ú tu (= kód IBAN) / international bank account number (IBAN Code) - název banky / name of the bank - adresa banky / address of the bank - identifika ní kód banky (BIC/SWIFT) / bank identification code (BIC/SWIFT) šekem na adresu mého bydlišt / by cheque to my address: 8 Prohlášení žadatele(ky) / Applicant s declaration Prohlašuji, že jsem veškeré údaje uvedl(a) podle pravdy. Jsem si v dom(a), že nepravdivé údaje mohou p ivodit nejen odn tí neprávem získaného d chodu a vymáhání náhrady škody, ale i trestní stíhání. I declare that all the information provided by me is true and correct. I am aware that giving false information may result not only in the loss of the unlawfully obtained benefits and claims for damages but also in criminal prosecution. V / At dne / on: Den / Day síc / Month Rok / Year vlastnoru ní podpis žadatele(ky) / applicant s signature 5

8 CAN-CZ 1 POZNÁMKY 1) Rodné jméno i všechna d ív jší používaná p íjmení se vypl ují vždy, a to i u muž. 2) Údaj o rodném ísle se nevypl uje, pokud toto íslo nebylo p id leno. 3) Sirotek starší 18 let uplat uje nárok na sirot í d chod samostatnou žádostí pod svým rodným íslem. U sirotka mladšího 18 let je žadatelem žijící rodi. Uplat uje-li sirotek nárok na sirot í d chod po obou rodi ích, je nutno sepsat dv žádosti (u sirotka mladšího 18 let uplat uje nárok zákonný zástupce opatrovník). V takovém p ípad se v žádosti o sirot í d chod nevypl ují prohlášení o trvání manželství a uzav ení nového manželství (body 2.11 a 2.12). 4) Do p ehledu o dobách pojišt ní (zam stnání), innostech a náhradních dobách vypl te nejen údaje o zam stnání a samostatné výd le né innosti vykonávaných na území eské republiky a v Kanad, ale i údaje o zam stnání a samostatné výd le né innosti na území jiných stát (v etn názvu státu). Ve vý tu dob zam stnání lze pokra ovat na samostatn vloženém listu. 5) Osv ení dle zákona. 255/1946 Sb. vydané Ministerstvem vnitra eské republiky ( eskoslovenské republiky) (osv ení týkající se ú asti v odbojovém hnutí) je t eba p edložit v originále nebo notá sky ov ené fotokopii. POU ENÍ Žádost se zasílá eské správ sociálního zabezpe ení, K ížová 25, Praha 5, prost ednictvím kanadského nositele pojišt ní International Operations - AB, Service Canada, P.O.Box 2710, Main Station, Edmonton, Alberta T5J 4C2, CANADA. Kanadský nositel pojišt ní (International Operations) p ipojí k žádosti podrobnosti o Vašich dobách pojišt ní a/nebo dobách zam stnání v Kanad a postoupí ji eské správ sociálního zabezpe ení. Žádost doporu ujeme vyplnit iteln h lkovým písmem. K žádosti se dokládají ov ené kopie doklad. Doby pojišt ní a/nebo doby zam stnání v Kanad budou ú edn potvrzeny kanadským nositelem pojišt ní (International Operations). K žádosti o starobní nebo invalidní d chod se p edkládají ov ené kopie t chto doklad : - rodný list žadatele nebo jiný dokument, který obsahuje datum narození - doklad o studiu (i nedokon eném) - doklad o vojenské/civilní služb v Armád eské republiky ( eskoslovenské republiky) - ženy, které pe ovaly (pe ují) o d ti (dít ) vlastní, osvojené nebo p evzaté do pé e nahrazující pé i rodi, p edkládají ov ené kopie rodných list d tí (dít te) a u osvojených d tí rozhodnutí soudu o osvojení - osobní list d chodového zabezpe ení (pojišt ní), pokud Vám byl eskou správou sociálního zabezpe ení vydán. K žádosti o poz stalostní d chod se p edkládají ov ené kopie t chto doklad : - rodný list žadatele (žadatelky) nebo jiný dokument, který obsahuje datum narození - rodný list zem elé(ho) - doklad o studiu zem elé(ho) (i nedokon eném) - doklad o vojenské/civilní služb zem elého v Armád eské republiky ( eskoslovenské republiky) - pe ovala-li zem elé žena o d ti (dít ) vlastní, osvojené nebo p evzaté zem elou ženou do pé e nahrazující pé i rodi, edloží se ov ené kopie rodných list t chto d tí (dít te) a u osvojených d tí rozhodnutí soudu o osvojení - osobní list d chodového zabezpe ení (pojišt ní) zem elé(ho), pokud byl eskou správou sociálního zabezpe ení vydán - oddací list, p íp. výpis z matriky oddaných (pouze u žádosti o vdovský vdovecký d chod) - úmrtní list manžela(ky) (rodi e dít te) - v p ípad, že žadatel(ka) o vdovský/vdovecký d chod pe uje o nezaopat ené dít (d ti), a to jak vlastní, tak osvojené nebo evzaté do pé e nahrazující pé i rodi, je nutno p ipojit ov enou kopii rodného listu dít te (d tí). Jde-li o dít (d ti), které již ukon ilo(y) povinnou školní docházku, je t eba doložit jeho (jejich) nezaopat enost potvrzením o studiu, event. u ení, p íp. dalšími doklady prokazujícími nezaopat enost (doklad o zdravotním stavu dít te). Pokud již byly n které doklady p iloženy k d ív jší žádosti, není t eba je znovu p ikládat. Vypln ný tiskopis zašlete, prosím, na adresu: International Operations - AB Service Canada P.O.Box 2710, Main Station Edmonton, Alberta T5J 4C2 CANADA 6

9 CAN-CZ 1 NOTES 1) Both male and female applicants shall in his (her) last name at birth and all previous last names. 2) If you have not been assigned a Birth Certificate Number, leave the line blank. 3) An orphan of 18 years of age or older applies for an orphan s pension on a separate application form under his/her Birth Certificate Number. A parent applies for an orphan s pension on behalf of an orphan under 18 years of age. If an orphan applies for an orphan s pension after both parents have died, two applications must be completed (a legal guardian applies on behalf of an orphan under 18 years of age). In such cases the lines 2.11 and 2.12 pertaining to the continuation of the marriage and entering into a subsequent marriage are to be left blank in an application for an orphan s pension. 4) In the list of insurance periods (employment periods) and substitute insurance periods, please mention all employment or self-employment performed in the Czech Republic and in Canada as well as in other countries (including the name of the country). The list of insurance periods may continue on an additional sheet. 5) The original or notarized copy of the certificate issued by the Ministry of Interior of the Czech Republic (Czechoslovak Republic) as per Act No. 255/1946 Coll. (certificate concerning Participation in the Resistance) must be enclosed. INSTRUCTIONS The application is to be sent to the Czech Social Security Administration, K ížová 25, Praha 5, through International Operations - AB, Service Canada, P.O.Box 2710, Main Station, Edmonton, Alberta T5J 4C2, CANADA. International Operations will attach details of your periods of insurance and/or periods of employment in Canada to your application and send it to the Czech Social Security Administration. Please complete this form legibly in block letters. Certified copies of documents are to be enclosed. Periods of insurance and/or periods of employment in Canada will be certified by International Operations. In case of a claim for an old age pension or for an invalidity pension, following documents (certified copies) are to be enclosed: - applicant s birth certificate or other document specifying date of birth - education certificates (even if the study was not completed) - certificates of military/civilian service in the Czech (Czechoslovak) Army - a female applicant who has reared (has been rearing) a child (children) either her own or adopted child (children) or a child (children) in foster care shall enclose birth certificate(s) of the child (children) or court decree of adoption - if available, applicant s Personal Records of Pension Insurance (osobní list d chodového pojišt ní) issued by the Czech Social Security Administration. In case of a claim for a survivor s pension, following documents (certified copies) are to be enclosed: - applicant s birth certificate or other documents specifying date of birth - birth certificate of the deceased person - education certificates (even if the study was not completed) - certificates of military/civilian service in the Czech (Czechoslovak) Army - if the deceased woman had been rearing a child (children) either her own or adopted child (children) or a child (children) in foster care a certified copy of birth certificate(s) of the child (children) or court decree of adoption shall be enclosed - if available, applicant s Personal Records of Pension Insurance (osobní list d chodového pojišt ní) issued by the Czech Social Security Administration - marriage certificate or an extract from Marriage Register (claim for a widow s or widower s pensions only) - death certificate of the deceased spouse (parent) - in case of a claim for a widow s/widower s pension by an applicant who is rearing a dependent child (children) either her/his own or adopted child (children) or a child (children) in foster care a certified copy of birth certificate(s) of child (children) shall be enclosed. If the child (children) already completed a compulsory school attendance, please enclose also a certificate of school attendance or any other documents proving that the child is dependent (medical certificates). Documents enclosed with a previous application do not need to be provided again. Please send the completed form to: International Operations - AB Service Canada P.O.Box 2710, Main Station Edmonton, Alberta T5J 4C2 CANADA 7

10 Canada / Czech Republic Agreement Documents and/or information required to support your application [CAN-CZ 1] for a Czech Old Age and/or Invalidity Pension Complete the attached forms: Canadian Residence [SC ISP5013] (only if you are applying for a Czech Old Age pension and are 65 years of age or over and have less than 15 years of contribution to the Canada Pension Plan or are less than 65 years of age and have less than 25 years of contribution to the Canada Pension Plan) Medical Report (only if you are applying for a Czech Invalidity pension) Original or certified documents to be submitted: Birth certificate for you and any children declared on the application form CAN-CZ 1 Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as: Immigration 1000, passport, visa, ship or airline tickets, etc.) (only if you are applying for a Czech Old Age pension and are 65 years of age or over and have less than 15 years of contribution to the Canada Pension Plan or are less than 65 years of age and have less than 25 years of contribution to the Canada Pension Plan] Documents supporting your employment in the Czech Republic Documents supporting your post-secondary education, occupational training or apprenticeship (if applicable) Documents supporting your Czech military or civilian service (if applicable) Certificate of your employment periods outside Canada and the Czech Republic (if applicable) Proof of adoption of children (if applicable) Original documents to be submitted: Certificate from the Czech Department of Defense confirming your periods of participation in the Resistance Movement (if applicable) (a notarized copy can also be submitted) IMPORTANT: If you have already submitted any of the documents required when you applied for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them.

11 Canada / Czech Republic Agreement Documents and/or information required to support your application [CAN-CZ 1] for a Czech Survivor s Pension Original or certified documents to be submitted: Birth certificate for you, the deceased and any children declared on the application form CAN-CZ 1 Marriage certificate (if applicable) Death certificate Documents supporting the deceased s employment in the Czech Republic Documents supporting the deceased s post-secondary education, occupational training or apprenticeship (if applicable) Documents supporting the deceased s Czech military or civilian service (if applicable) Certificate of the deceased s employment periods outside Canada and the Czech Republic (if applicable) Proof of adoption of children (if applicable) Original documents (if applicable) to be submitted: Certificate from the Czech Department of Defense confirming the deceased s periods of participation in the Resistance Movement (a notarized copy can also be submitted) Medical evidence if you are a widow under age 55 or a widower under age 58 who does not have dependent children Proof of school attendance or occupational training/apprenticeship for children between 18 and 26 who are attending school Medical evidence for a child over age 18 who is unable to attend school or work due to a longterm state of health IMPORTANT: If you have already submitted any of the documents required when you applied for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them.

12 Service Canada PROTECTED B (when completed) Personal Information Bank ESDC PPU 175 CANADIAN RESIDENCE Canadian Social Insurance Number: Mr. Mrs. Ms. Miss Given Name and Initial Family Name The following information is required to support your application for benefits under a social security agreement. If required, please provide additional information on a separate sheet of paper. 1. If you were born outside of Canada, please provide us with the following information: Date of arrival in Canada (YYYY-MM-DD): Place of arrival in Canada: 2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries and departures (Permanent Resident card, Record of Landing (IMM 1000), complete passport, airline tickets, etc.): From YYYY-MM-DD To YYYY-MM-DD City Province/Territory 3. List all absences from Canada, which were longer than six months, during your Canadian residence listed in number 2 above: Departure YYYY-MM-DD Return YYYY-MM-DD Destination Reason Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada. SC ISP-5013 ( ) E 1 of 2 Disponible en français

13 Canadian Social Insurance Number: PROTECTED B (when completed) 4. Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood or marriage, who can confirm your Canadian residence: Name Address City Telephone Number DECLARATION OF APPLICANT I declare that this information is true and complete. NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid. Signature Date (YYYY-MM-DD) X Telephone number SC ISP-5013 ( ) E 2 of 2

14 Czech Social Security Administration, Foreign Affairs Department, Czech Republic Česká správa sociálního zabezpečení, Oddělení mezinárodních agend, Česká republika MEDICAL REPORT / LÉKAŘSKÁ ZPRÁVA PIN.. for the medical evaluation of the long-term health status of a person residing in Canada who wishes to apply for a disability pension paid by the Czech Social Security Administration / pro posouzení dlouhodobě nepříznivého stavu osoby žijící v Kanadě a uplatňující žádost o přiznání invalidního důchodu z českého důchodového pojištění Requested on / vyžádáno dne. received / došlo dne PERSON EXAMINED / VYŠETŘOVANÁ OSOBA birth number in the CR / rodné číslo. Surname / Příjmení... Forenames / Jméno... date of birth / datum narození family status / stav..... Address / Bydliště... Education, professional training (trade) /... Vzdělání, odborná průprava (vyučen) Employer / Zaměstnavatel... Last employment, workplace address, position /... Poslední zaměstnání, pracoviště, funkce Sickness benefits drawn / Nemocenské pobíral from / od... to / do... for illness / pro chorobu.. Disability pension received / Důchod invalidní pobíral from / od... to / do... (still being received since / never granted )... (pobírá od / nikdy nepřiznán )... MEDICAL FINDINGS / LÉKAŘSKÝ NÁLEZ PATIENT HISTORY / ANAMNÉZA (based on information provided by the patient / podle subjektivních údajů nemocného) * 1. family history (hereditary diseases if any) / rodinná anamnéza (event. zátěž) 2. life style (sleep, diet, smoking, alcohol) / životospráva (spánek, dieta, kouření, pití) * In follow-up examinations, emphasize any changes since last check-up / u kontrolních prohlídek uvádějte především veškeré údaje (změny) od poslední prohlídky.

15 3. social history (housing, family relationships, number of children, etc.) / sociální anamnéza (bydlení, rodinné poměry, počet dětí a j.) 4. detailed work history (qualifications, detailed employment history, work load, shift work, commuting, any risk factors, type of work applicant is interested in in case of employment termination due to health reasons) / podrobná pracovní anamnéza (kvalifikace, podrobný popis průběhu zaměstnání, pracovní úvazek, směnnost, cesty do práce, event. rizika, o jaké zaměstnání se zajímá při event. vyřazení ze zdravotních důvodů) 5. medical history (past illnesses, injuries, hospitalizations, operations, etc.) / předchorobí (prodělaná onemocnění, úrazy, hospitalizace, operace, aj.) 6. current illnesses / nynější onemocnění 7. subjective problems and symptoms (their origin and course, duration) / subjektivní potíže a příznaky (jejich vznik a průběh, délka trvání) 8. time from which patient has felt incapable of performing his work duties and/or any continuous occupation, or under what conditions does he consider he can work, etc. / od kdy se cítí neschopen vykonávat své zaměstnání, popř. jakoukoliv soustavnou činnost nebo za jakých podmínek se cítí schopen pracovat a pod. 9. treatment (please list type, duration and response, current medication) / léčení (jaké, trvání, výsledek, současné léky)

16 OVERALL OBJECTIVE FINDINGS / CELKOVÝ OBJEKTIVNÍ NÁLEZ (give your opinion on all subjective data / zaujmout stanovisko ke všem subjektivním údajům) General state of health (physical examination) and description of all pathological changes (in follow-up examinations, describe especially those changes that have occurred since the last check-up), including a description of any functional handicaps / Celkový stav (fysikální vyšetření) a popis všech chorobných změn (u kontrolních prohlídek zejména změn nastalých od posledního vyšetření) včetně popisu postižení funkčního Height / Výška... Weight / Váha...BP / TK...

17 RESULTS OF SPECIALISTS EXAMINATIONS / VÝSLEDKY ODBORNÝCH VYŠETŘENÍ (including laboratory tests, clinical tests, etc., giving the name of the specialized clinic and the date of examination, in the form of an accurate certified transcript or its certified photocopy, and including a description of any functional handicap / včetně vyšetření laboratorních, přístrojových apod. s uvedením odborného pracoviště a data vyšetření ve výstižném ověřeném opise nebo ověřené kopii, a včetně postižení funkčního)

18 CLINICAL DIAGNOSIS / KLINICKÁ DIAGNÓZA: FUNCTIONAL DEFICIENCIES / ZHODNOCENÍ FUNKČNÍHO POSTIŽENÍ summary of the patient s functional limitations / shrnutí funkčních postižení pacienta PROGNOSIS / PRAVDĚPODOBNÝ DALŠÍ VÝVOJ (both as to the illness and rehabilitation / z hlediska choroby i z hlediska rehabilitace). Space for any further findings and additional comments / Místo pro případné další nálezy a záznamy: Date, stamp of health institution, name and signature of treating physician / Datum, razítko zdravotnického zařízení, jmenovka a podpis ošetřujícího lékaře