Fillable Standard Form 3112a - Applicant'S Statement Of Disability (Page 4 of 10) in pdf

Supervisor's Statement

In Connection With Disability Retirement Under the Civil Service Retirement System

and the Federal Employees Retirement System

Civil Service

Federal Employees

Retirement System

This form should be completed by the immediate supervisor

or someone who is in a position to observe the applicant on a regular basis.

Form Approved:

OMB No. 3206-0228

Instructions

All sections of this form must be completed properly.

"Unsatisfactory conduct" means conduct for which an

Failure to do so will delay the processing of the disability

employee may be removed or disciplined for cause under

application at OPM.

adverse action procedures. (For example, discourteous

conduct to the public, behavior which poses a threat to the

The employee identified in Section A has indicated that he or

life, health, safety, or well-being of co-workers, subordinates,

she intends to apply for disability retirement. The applicant's

or the public.)

signature on the "Applicant's Statement" authorizes his or her

immediate supervisor (or a supervisor who was and is in a

"Accommodation" means an adjustment made to a job and/or

position to observe the applicant on a regular basis) to provide

work environment that enables a qualified handicapped person

the information and documentation requested. The immediate

to perform the duties of that position. Reasonable accommo-

supervisor is asked to provide information about the applicant's

dation may include modifying the worksite, adjusting the

job, performance, attendance, and conduct.

work schedule, restructuring the job, acquiring or modifying

equipment or devices, providing interpreters, readers or

If you need more space in any section, attach a separate sheet

personal assistants, and reassigning or retraining employees.

and indicate that an attachment is provided.

The following definitions apply to the terms used in the

"5 CFR 531.409(d)" is the regulation that provides for a

Supervisor's Statement.

waiver of the requirements for determination of an employee's

level of competence in certain cases when the employee was

"Less than fully successful performance" means performance

in duty status for less than 60 days during the 52 calendar

of an employee which fails to meet established performance

weeks before a within-grade increase would be due.

standards in one or more critical elements of the employee's

position or the equivalent level for a position not under CFR

After completing and certifying this form and attaching the

430.

appropriate documentation, you should return the original to the

employee or to your personnel office according to instructions

"Critical element" means a component of an employee's job

and practices in your agency. In either case, a copy must be given

that is of sufficient importance that performing below the

to the employee. Please do not send the form directly to OPM

minimum standard established by management requires

unless OPM specifically requested you to do so.

remedial action, such as denial of within-grade increase, and

may be the basis for reducing the grade level or removing the

If necessary, you may be contacted by OPM for additional

employee.

information or clarification.

"Unacceptable attendance" means absence from work which

is too frequent, unpredictable, or lengthy to allow the job to be

done.

Section A - Applicant Identification

1. Name

2. Date of birth (mm/dd/yyyy)

3. Social security number

(last, first, middle)

Section B - Information About Employee's Performance

(See instructions above)

2. Date of entry into position

1. Title of position of record. (Attach a copy of position description and current performance standards.

(mm/dd/yyyy)

If available, attach a copy of the latest performance appraisal.)

3. Is performance less than fully successful in any critical element of position?

Yes, complete items 4 - 6 of this section.

No, go to Section C.

4. Show the approximate date (mm/yyyy)

5. After the date in item 4, has the employee received a within-grade step

5a. Was within-grade

that unacceptable performance or the

increase or an award based on performance of a critical element?

increase granted under 5

inability to do the job began.

CFR 531.409 (d)? (see

Period the increase or award covered.

instructions)

From (mm/yyyy)

To (mm/yyyy)

Yes

3112-103

Standard Form 3112B

Original - To OPM Through Agency Channels

Revised May 2011

U.S. Office of Personnel Management

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous edition is usable

Standard Form 3112a - Applicant'S Statement Of Disability Page 4

Related Articles

Related forms

Related Categories