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

Forms and Documents

Document Name	Status
Form SF 3112 CSRS/FERS Documentation in Support of Disability Retirement Application Form and Instruction	Modified
30-Day FRN.pdf Supplementary Document	2013-03-28
60-day FRN.pdf Supplementary Document	2013-03-28
SF3112-2.pdf Supplementary Document	2013-03-28
SF3112-1.pdf Supplementary Document	2013-03-28
SF 3112 SS.doc Supporting Statement A	2013-03-28

IC Document Collections

IC ID	Document Title	Status
33732	CSRS/FERS Documentation in Support of Disability Retirement Application Form and Instruction	Modified

ICR Details

OMB Control No: 3206-0228	ICR Reference No: 201303-3206-005
Status: Historical Active	Previous ICR Reference No: 201004-3206-011
Agency/Subagency: OPM	Agency Tracking No:
Title: SF 3112, CSRS/FERS Documentation in Support of Disability Retirement Application
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/05/2013
	Date Received in OIRA: 03/28/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved	07/31/2013
Responses	13,450	0	13,450
Time Burden (Hours)	12,775	0	12,775
Cost Burden (Dollars)	0	0	0

---

Abstract: SF 3112 collects information from applicants for disability retirement so that OPM can determine whether to approve a disability retirement. The applicant will only complete Standard Forms 3112A and 3112C. Standard Forms 3112B, 3112D and 3112E will be completed by the immediate supervisor and the employing agency of the applicant.

---

Authorizing Statute(s): US Code: 5 USC Section 8451 Name of Law: Disability Retirement (FERS)
   US Code: 5 USC Section 8337 Name of Law: Disability Retirement (CSRS)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 66189	11/02/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 79026	03/28/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
CSRS/FERS Documentation in Support of Disability Retirement Application	SF 3112	CSRS/FERS Documentation in Support of Disability Retirement Application

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	13,450	13,450	0	0	0	0
Annual Time Burden (Hours)	12,775	12,775	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $1,123,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/28/2013

---