Sf 3112 Ss

OMB SUPPORTING STATEMENT

SF 3112 – CSRS/FERS Documentation in Support of Disability Retirement Application

A. Justification

1. Sections 8337 and 8451, et seq., title 5, United States Code, provide that the Office of Personnel Management (OPM) determines whether employees and former employees who apply for disability retirement are eligible for that benefit. Subject to the authority provided in 5 USC, OPM has prescribed regulations, contained in 5 CFR 831, Subpart L and 844 to administer the provisions of 5 USC.

SF 3112 and its associated forms –

SF 3112A - Applicant’s Statement of Disability

SF 3112B - Supervisor’s Statement

SF 3112C - Physician’s Statement

SF 3112D - Agency Certification of Reassignment and Accommodation Efforts

SF 3112E - Disability Retirement Application Checklist

are designed to collect information for disability retirement purposes. SF 3112, supplemented by the information contained in SF 3112-1, Information about Disability Retirement (CSRS), and SF 3112-2, Information about Disability Retirement (FERS), is a complete information and instruction package for persons who wish to apply for disability retirement. These forms stipulate the documentation and eligibility requirements contained in the law and regulation. Information is collected from the applicant, the agency, and the applicant’s private physician. The law defines employees eligible to apply for disability retirement to include separated employees who apply within one year of the date of separation.

2. The information collected is used by OPM to determine the allowance or disallowance of disability retirement applications. Both SF 3112A and SF 3112C collect information about the disabling condition of the applicant. The form was revised to bring the Privacy Act and Public Burden statements up-to-date and to collect email addresses on SF 3112A, D, and E. If information about the disability were not collected, OPM would be unable to determine whether the applicant meets the legal requirements for disability retirement. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b)(3).

2. The information collected is detailed and can only be obtained from the respondents. New methods of information technology would do little to reduce the burden on the respondents; they must sign the application attesting to its truth, under penalty of law, to the best of their knowledge. However, this form is available in a PDF fillable format on our website and meets the GPEA requirements.

2. Applications are filed individually. There is no similar information available. Duplication is minimized.

2. Information is not collected from small businesses.

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2. The collection of this information is performed as needed to pay eligible persons. Less frequent collection would delay the payment of annuities provided by law.

2. This collection is consistent with the guidelines of 5 CFR 1320.6.

2. A notice of proposed information collection was published in the Federal Register on November 12, 2009, giving persons outside the agency an opportunity to comment on the forms. No comments were received.

2. OPM does not provide any payment or gift to the respondents, other than paying any benefits provided by law.

2. This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106 and 5 CFR 841.108). The routine uses for disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008).

2. The information collection does not include questions regarding sexual behavior and attitudes or religious beliefs. However, SF 3112 does collect information regarding the applicant’s medical condition so that OPM can determine whether the applicant is able to perform the duties shown in the position description. The applicant’s physician responds to SF 3112C. The applicant is aware that OPM needs the medical documentation. The applicant desires to be considered for disability retirement and indicates consent to the release of private information to OPM by signing the SF 3112 and by taking it to the physician of his choice for completion and submission to OPM.

2. Approximately 12,100 disability retirements are processed annually. We estimate it takes one hour to fill out SF 3112C. A burden of 12,100 hours is estimated for SF 3112C. SF 3112A is used each year by approximately 1,350 persons who are not Federal employees. We estimate it takes 30 minutes to fill out SF 3112A. A burden of 675 hours is estimated for SF 3112A. The total burden for SF 3112 is 12,775 hours.

All 12,100 respondents must use SF 3112C; of the 12,100, only 1,350 respondents are not Federal employees and use SF 3112A.

2. We estimate that respondents pay $150 to $200 to obtain needed medical records and physician’s statements to apply for disability retirement.

2. The annualized cost to the Federal government is $1,123,500. This cost includes employee salary hours devoted to the program, forms cost, and overhead.

2. There are no changes or adjustments.

2. The results of this information collection are not published.

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2. It is not cost effective to reprint the whole supply of forms to change the OMB clearance expiration date. Therefore, we seek approval not to display the date on the form.

2. There are no exceptions to the certification statement.