Standard Form 3112a - Applicant'S Statement Of Disability Page 2
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10Applicant's Statement of Disability
In Connection With Disability Retirement Under the Civil Service Retirement System or
Civil Service
Federal Employees
the Federal Employees Retirement System
Retirement System
Retirement System
A copy of this completed form must accompany the Supervisor's Statement you give
Form Approved:
your supervisor(s).
OMB No. 3206-0228
1.
Name (last, first, middle)
2. Date of birth (mm/dd/yyyy)
3. Social security number
4.
Fully describe your disease(s) or injury(ies.) We consider only the diseases and/or injuries you discuss in this application.
5.
Describe how your disease(s) or injury(ies) interferes with performance of your duties, your attendance, or your conduct.
6.
Describe any other restrictions of your activities imposed by your disease or injury.
7a.
What accommodations have you requested from your agency?
7b. Has your agency been able to grant your request? (Attach an explanation or any documentation that you have regarding accommodation.)
Yes
No
What is your current status with your agency?
7c.
In pay status; and working without accommodation.
In leave without pay status.*
In pay status; and working with accommodation.
Separated from service*
*If you are currently in a leave without pay status or separated from service, what job(s), if any, have you performed since going into this status?
Please explain the physical and/or mental requirements for this (those) job(s).
9. Have you been
8.
Give the approximate date you became disabled for your
10. Give date of most recent hospitalization.
hospitalized for your
position (mm/yyyy).
From (mm/yyyy)
To (mm/yyyy)
disease or injury as
described in item 4?
Yes
No
11. Notice for FERS and CSRS Offset Applicants ONLY
Application for disability retirement under FERS or CSRS Offset requires an application for Social Security Disability Benefits. Final
processing at OPM cannot be completed without a copy of your Social Security application receipt or award notice.
11a. Have you applied for disability benefits from the Social Security
11b. Is the application receipt or award notice attached?
Administration?
Yes
No
Yes
No
Standard Form 3112A
7540-01-385-7215
3112-103
Revised May 2011
U.S. Office of Personnel Management
Previous edition is usable
CSRS/FERS Handbook for Personnel and Payroll Offices
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