Fillable Standard Form 3112a - Applicant'S Statement Of Disability (Page 6 of 10) in pdf

Physician'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

Applicant must attach a copy of the most current position description

Form Approved:

OMB No. 3206-0228

Section A - Identifying Information and Consent

(to be completed by applicant)

1. Applicant's name (last, first, middle)

3. Social security number

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

4. Enter exact name and address (including ZIP Code).

If you are currently employed by your agency or

separated for less than 30 days, enter exact name

and address including the name of the person or

office in your employing agency

where this information should be mailed.

If you have been separated from your

employing agency for 31 days or more

provide your current home address.

5. I authorize the release to the Office of Personnel Management and my employing agency of any

Applicant's Consent to Release

and all information or records connected with my disability retirement application.

Medical Information

Signature (do not print)

Date (mm/dd/yyyy)

Privacy Act and Public Burden Statements

Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and the Federal Employees

Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your

application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a

uniquely identifiable claim file. The information may be shared and is subject to verification, via paper, electronic media, or through the use of

computer matching programs, with national, state, local or other charitable or social security administrative agencies in order to determine benefits

under their programs, to obtain information necessary for determination or continuation of benefits under this program, or to report income for tax

purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or potential

violation of civil or criminal law. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Furnishing the

data requested is voluntary, but failure to do so will delay or prevent action on the retirement application.

We estimate this form takes an average 60 minutes per response to complete, including the time for reviewing instructions, getting the needed data,

and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing

completion time, to the Office of Personnel Management (OPM), Retirement Services Publications Team (3206-0228), Washington, DC

20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and you are not required to respond, unless

this number is displayed.

Section B - Medical Documentation (to be completed by physician)

Instructions

The individual identified above is requesting medical documentation that will be evaluated, along with non-medical documentation,

in connection with his or her application for disability retirement from Federal Government service. Please include all objective

findings and reports concerning the individual's condition. This documentation may also be used in determining his or her eligibility

for reassignment to a position that he or she is medically able to perform. A copy of his or her position description is attached for

your information.

Please provide the medical documentation requested under "Medical Documentation Requirements" on your letterhead

stationery. It is important that you respond to every item listed. Enter the item number of the information requested and

provide your response. If an item is not applicable to the applicant's medical condition, enter "Not Applicable." Include in

your statement the identifying information in Section A, items 1 through 3, above. Your failure to provide complete infor-

mation will delay the processing of your patient's disability retirement application.

Enclose your report and any attachments in a sealed envelope marked "Medical Disability - Privileged - Private." Please make

sure copies of all medical reports referenced in your statement are included. Send the envelope to the address shown in item 4

above. You may, if you wish, give it directly to the applicant for delivery to the appropriate office.

Continued on reverse

3112-103

Standard Form 3112C

U.S. Office of Personnel Management

Revised May 2011

CSRS/FERS Handbook for Personnel and Payroll Offices

Previous edition is usable

Standard Form 3112a - Applicant'S Statement Of Disability Page 6

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