Fillable Standard Form 3112a - Applicant'S Statement Of Disability (Page 8 of 10) in pdf

Agency Certification of Reassignment and Accommodation Efforts

In Connection With Disability Retirement Under the Civil Service Retirement System

Civil Service

Federal Employees

and the Federal Employees Retirement System

Retirement System

Form Approved:

OMB No. 3206-0228

Instructions

The Coordinator for Employment of the Handicapped should

The documentation supporting your response to item 4 must

review the Applicant's Statement, the Supervisor's Statement,

include an assessment of the functional and environmental

the Physician's Statement, and any other relevant documen-

factors related to the employee's inability to perform at the fully

tation on file to determine if reasonable accommodation will

successful level, unless there are no medical restrictions.

enable the employee to perform fully successful service in his

Reassignment (item 5) - Guidance related to reassignment of

or her current position or whether a vacant position is available

an applicant for disability retirement is published in OPM's

in the agency, at the same grade or pay level in the same com-

"CSRS and FERS Handbook for Personnel and Payroll

muting area, for which the employee is qualified for reassign-

Offices".

ment. Take special note of the Supervisor's Statement and

resolve any discrepancies between the information on that form

After completing and certifying this form, please attach the

and this form. Telephone numbers for the applicant, the super-

appropriate documentation and return the original to the

visor, and the physician may be found on their respective

employee or to your personnel office according to instructions

statements, should it be necessary to contact them for further

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

information.

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

If the employee is eligible to retire voluntarily, the employee

OPM unless OPM specifically requested you to do so in this

should be advised of that fact. In general there is no difference

case.

in the payment to a disabled annuitant and an optionally retired

annuitant, nor are there Federal tax advantages for a disability

Your agency's obligation to continue to try to accomodate or

retiree.

reassign the employee does not cease with the filing of this

certification. Your efforts should continue. If the accomm-

odation or reassignment situation changes after the original

All items must be completed. In items 4, 5, and 6, if you check

a box that requires additional explanation, please provide the

filing of the certification, you must notify OPM of the changes.

explanation and/or attachment. This will enable us to process

the application without delay.

OPM may contact you for additional information or

clarification.

Accommodation (item 4) - Guidance for determining reason-

able accommodations may be found in 29 CFR 1614.203(c).

To be completed by Coordinator for Employment of the Handicapped or other authorized agency official.

See instructions at the top of this page

1. Name of applicant (last, first, middle)

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

3. Social security number

4. Has reasonable effort for accomodation been made? (You must check one statement below.)

No, the medical evidence presented to the agency shows that accommodation is not possible due to severity of medical condition and the

physical requirements of the position. (Attach copies of all medical evidence supporting the statement and explain why conditions prohibit

accommodation. Also, provide a detailed statement of the physical requirements of the position.) Employees should be counseled concerning

the following: The fact that your agency has determined accommodation to be unavailable due to status of a medical condition or due to

restriction imposed by a physician does not guarantee that OPM will reach the same decisions about the approval of a disability retirement

application.

No, the employee's condition does not appear to require accommodation. Medical information presented to agency does not document a

disabling medical condition.

Yes, describe below accommodation efforts made, attach supporting documentation and provide narrative analysis of any unsuccessful

accommodation efforts.

Continued on reverse

Standard Form 3112D

3112-103

Duplicate - Employee's Copy

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 8

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