OPM 1530, Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OPM 1530 Report of Medical Examination of Person Electing Survivor Benefits	Form and Instruction	Modified	Available
OPM1530_30DayFRN_Published_2017_05_05.pdf	Supplementary Document	Uploaded 2017-05-12	Available
OPM 1530 March 2017_Mark up copy.pdf	Supplementary Document	Uploaded 2017-03-30	Available
OPM 1530_ revised _2011.pdf	Supplementary Document	Uploaded 2017-03-30	Available
OPM 1530 60 Day FRN_8 _10_2016.pdf	Supplementary Document	Uploaded 2017-03-22	Available
OPM1530_OMBSupportStmt_2017_04_11.doc	Supporting Statement A	Uploaded 2017-05-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33635	Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System	Form and Instruction	Modified	Report of Medical Examination of Person Electing Survivor Benefits

ICR Details

OMB Control No: 3206-0162	ICR Reference No: 201703-3206-003
Status: Historical Active	Previous ICR Reference No: 201402-3206-006
Agency/Subagency: OPM	Agency Tracking No:
Title: OPM 1530, Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/02/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/15/2017
Terms of Clearance: OPM should review the privacy act statement on the form before it it next submitted for OMB review. In addition, please provide the most recent PIA and SORN with the renewal materials. This collection should be reported in the information collection budget.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2020	6 Months From Approved
Responses	500	0	0
Time Burden (Hours)	750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: OPM Form 1530 is designed to collect information from both the applicant and the applicant’s physician regarding the applicant’s health. This information is used to determine whether the insurable interest survivor benefits election can be allowed. The form has been revised to bring it up-to-date. Specifically, solicitation of this information is also authorized by the Federal Employees Retirement System (Chapter 84, title 5, United States Code).

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Authorizing Statute(s): US Code: 5 USC 8339(k)(I) Name of Law: Civil Service Retirement
   US Code: 5 USC 84 Name of Law: Federal Employees Retirement
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 52915	08/10/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21274	05/05/2017
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System	OPM 1530	Report of Medical Examination of Person Electing Survivor Benefits

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ICR Summary of Burden

table that charts list 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	500	0	0	0	0	500
Annual Time Burden (Hours)	750	0	0	0	0	750
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:

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Annual Cost to Federal Government: $24,150

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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

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Common Form ICR:  No

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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: 05/15/2017

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