Standard Form 3112a - Applicant'S Statement Of Disability Page 7
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10Instructions (continued)
Please complete this statement within 2 weeks. Be sure to sign the report. Include your address and telephone number.
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The applicant is responsible for any costs incurred in connection with providing this documentation.
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Medical Documentation Requirements
You must provide the following information:
disorders, provide the results of mental status examinations,
personality tests, test of cognitive function, educational
1. A comprehensive history of this patient's medical con-
evaluation, neuropsychiatric tests, etc.
dition(s). This must include detailed information regarding
the symptoms and history, past and current physical
3. Diagnosis of patient's condition(s). Preferably each
findings, results of laboratory studies and therapy of this
diagnosis should be found in the current publication
condition(s). The medical documentation must contain
"International Classification of Disease". In the case
specific information to show why this patient is not able to
of psychiatric disorders, diagnostic titles and codes
perform his or her duties. The medical documentation
from the DSM III(R) should be used.
should not be conclusory. Provide a discussion of patient
compliance with therapy, response to therapy, and plans for
4. An assessment of the degree to which the medical con-
future therapy. Also, provide copies of pertinent hospital-
dition(s) has or has not become static and an estimate of
ization summaries and operative reports.
the expected date of full or partial recovery or remission.
2. Copies of reports of all applicable diagnostic laboratory
5. If restrictions have been placed on this patient's activities,
tests (e.g. hematologic, chemistry, electrophysiologic,
please state what they are, why they have been imposed,
radiologic, nuclear medicine, etc.) In the case of psychiatric
and how long you expect these to be in effect.
General Information
Disability retirement determinations are made in accordance
area at the same grade or pay level and tenure, for which the
with Federal retirement regulations. A person is entitled to
employee is qualified for reassignment. Useful and efficient
disability retirement benefits only when the information
service means fully successful performance of the critical or
submitted with the application shows that an employee is
essential elements of the position (or the ability to perform at
unable to perform useful and efficient service because of
that level) and satisfactory conduct and attendance.
disease or injury (1) in the employee's current position or (2)
within a vacant position, in the same agency and commuting
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Reverse of Standard Form 3112C
3112-103
Revised May 2011
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