Standard Form 3112a - Applicant'S Statement Of Disability Page 5
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106. Identify any critical element(s) of the position which employee does not perform successfully or at all. Explain the deficiencies you observed.
Attach supporting documentation such as notice to the employee that performance is less than fully successful or physician's recommendation
regarding medical restrictions.
Section C - Information About Employee's Attendance
1. Has employee stopped coming to work?
No
Yes, how long is absence expected to continue (if known)?
2. Is employee's attendance unacceptable for continuing in current position?
No
Yes, attendance stopped or became unacceptable on (mm/yyyy):
3.
Explain the impact of employee's absence on your work operations.
Annual
Sick
LWOP
4. How many hours of leave has employee used for apparent medical reasons since date in item
Enter Leave
C2? (Attach copies of medical information on which you based your decision to approve
Hours Used
leave, leave records, records of contact with or notices to employee. Include as much
information as possible about specific reasons for leave use.)
Section D - Information About Employee's Conduct
1. Is employee's conduct unsatisfactory?
No, go to Section E.
Yes, conduct became unsatisfactory on (mm/yyyy):
2. Describe how conduct is unsatisfactory (attach supporting documentation, such as notice to employee of proposed adverse action).
Section E - Accommodation and Reassignment
(Consult with agency Coordinator for Employment of the Handicapped)
1. What efforts have been made to accommodate the employee in current position?
2. Has employee been reassigned to a new permanent position? (If yes, to what position and when?)
3. Has employee been reassigned to "light duty"
or a temporary position?
No, go to Section F.
Yes
No
Yes, to
on (mm/yyyy):
4. Describe the reason for temporary nature of assignment and length of time the employee is expected to occupy the position.
Section F - Supervisor's Certification
1. How long have you supervised the employee?
2d. Supervisor's office mailing address
2. I certify that all statements made on this Supervisor's
Statement are true to the best of my knowledge and belief.
2a. Supervisor's signature
2c. Date (mm/dd/yyyy)
2e. Supervisor's daytime telephone number (including area code)
2b. Supervisor's name (type or print legibly)
2f. Email address
PRINT
SAVE
CLEAR
Reverse of Standard Form 3112B
3112-103
Revised May 2011
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