Standard Form 3112a - Applicant'S Statement Of Disability Page 9
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105. Results of agency reassignment efforts (You must check one statement below.)
Reassignment is not necessary because employee's performance is fully successful and there are no medical restrictions which keep the
employee from performing critical duties or from attending work altogether.
Reassignment is not possible. There are no vacant positions at this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications standards.
The employee declined reassignment to a vacant position(s) in this agency at the same grade or pay level and tenure, within the same
commuting area, for which the employee meets minimum qualifications. (Attach a copy of any reassignment offers.)
The agency did not reassign the employee to the vacant position(s) in this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications. The position(s) identified and reason(s) for non-assignment are shown
below.
Position Title
Reason for Non-Reassignment or Non-Selection*
* If the employee's medical condition precludes reassignment to the position, attach documentation. If the reason for non-selection is intended
removal, attach a copy of the removal notice to the employee.
6.
Is the employee currently occupying a temporary position?
No, the employee is occupying a permanent position.
Not applicable, the employee is no longer an employee of the agency.
Yes, state below the nature of these duties, the reason for the temporary status, and length of time the agency expects the employee to occupy
this position.
Certification by Coordinator for Employment of the Handicapped or other authorized agency official.
7.
I certify that this statement is true to the best of my knowledge and belief.
7a. Signature of responsible agency official
7b. Title of responsible agency official
7c. Date (mm/dd/yyyy)
7d. Name of responsible agency official (type or print legibly)
7e. Telephone number (including area code)
7f. Email address
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Reverse of Standard Form 3112D
3112-103
Revised May 2011
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