SF3112_OMBSupportingStmt_2018_02_02

OMB SUPPORTING STATEMENT

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

1. Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

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. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

The information collected is used by OPM to determine the allowance or disallowance of disability retirement applications. Standard Forms 3112A and 3112C collect information about the disabling condition of the applicant. If information about the disability were not collected, OPM would be unable to determine whether the applicant meets the legal requirements for disability retirement. Revision to this information collection request includes editorial updates to the Privacy Act and Public Burden statements. The Public Burden Statement meets the requirements of 5 CFR 1320.8(b)(3).

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

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.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

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

5.  If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize.

This information collection request has no impact on small businesses and organizations.

6. Describe the consequence to Federal/DHS program or policy activities if the collection of information is not conducted, or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

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

7. Explain any special circumstances that would cause an information collection to be conducted in a manner:

• requiring respondents to report information to the agency more often than quarterly;

• requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;

• requiring respondents to submit more than an original and two copies of any document;

• requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records, for more than three years;

• in connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;

• requiring the use of statistical data classification that has not been reviewed and approved by OMB;

• that includes a pledge of confidentiality that is not supported by authority established in statute or regulation, that is not supported by disclosure and data security policies that are consistent with the pledge, or which is unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• requiring respondents to submit proprietary trade secrets, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

There are no special circumstances involved in the collection of this information.

8. Federal Register Notice: Provide a copy and identify the date and page number of publication in the Federal Register of the agency’s notice soliciting comments on the information collection prior to submission to OMB.

On April 13, 2017, a 60 Day Federal Register Notice was published at 82 FR 17893. There were no comments received.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

No gifts or payments of any kind have been provided to any individuals who are connected to this collection.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

This information collection is protected by the Privacy Act of 1974 and OPM regulations (5 CFR 831.106). The routine uses of disclosure appear in the Federal Register for OPM/Central-1 (73 FR 15013, et seq., March 20, 2008, effective April 21, 2008).

11. Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

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.

12. Provide estimates of the hour burden of the collection of information. The statement
should:

a. Indicate the number of respondents, frequency of response, annual hour burden,
and an explanation of how the burden was estimated. Unless directed to do so, agencies should not conduct special surveys to obtain information on which to base hour burden estimates. Consultation with a sample (fewer than 10) of potential respondents is desired. If the hour burden on respondents is expected to vary widely because of differences in activity, size, or complexity, show the range of estimated hour burden, and explain the reasons for the variance. Generally, estimates should not include burden hours for customary and usual business practices.

b. If this request for approval covers more than one form, provide separate hour
burden estimates for each form and aggregate the hour burdens in Item 13 of OMB Form 83-I.

c. Provide estimates of annualized cost to respondents for the hour burdens for
collections of information, identifying and using appropriate wage rate categories. The cost of contracting out or paying outside parties for information collection activities should not be included here. Instead, this cost should be included in Item 14.

Approximately 12,100 disability retirements are processed annually. All 12,100 respondents must use the SF 3112C. Only 1,350 respondents are not Federal employees and use SF 3112A.

We estimate it takes one hour to fill our SF 3112C. A burden of 12,100 hours is estimated for SF 3112C. 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 and its associated forms is 12,775 hours.

Form Name	Form Number	No. of Respondents	No. of Responses per Respondent	Average Burden per Response (in hours)	Total Annual Burden (in hours)	Average Hourly Wage Rate	Total Annual Respondent Cost
Applicant’s Statement of Disability Physician’s Statement	SF 3112A SF 3112C	1,350 12,100	1 1	30 minutes 1 hour	675 12,100	$0 $0	$0 $0

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

13. Provide an estimate of the total annual cost burden to respondents or record-keepers
resulting from the collection of information. (Do not include the cost of any hour burden
shown in Items 12 and 14.)

The cost estimate should be split into two components: (1) a total capital and start-up cost component (annualized over its expected useful life); and (b) a total operation and maintenance and purchase of services component. The estimates should take into account costs associated with generating, maintaining, and disclosing or providing the information. Include descriptions of methods used to estimate major cost factors including system and technology acquisition, expected useful life of capital equipment, the discount rate(s), and the time period over which costs will be incurred. Capital and start-up costs include, among other items, preparations for collecting information such as purchasing computers and software; monitoring, sampling, drilling and testing equipment; and record storage facilities.

If cost estimates are expected to vary widely, agencies should present ranges of cost burdens and explain the reasons for the variance. The cost of purchasing or contracting out information collection services should be a part of this cost burden estimate. In developing cost burden estimates, agencies may consult with a sample of respondents (fewer than 10), utilize the 60-day pre-OMB submission public comment process and use existing economic or regulatory impact analysis associated with the rulemaking containing the information collection as appropriate.

Generally, estimates should not include purchases of equipment or services, or portions thereof, made: (1) prior to October 1, 1995, (2) to achieve regulatory compliance with requirements not associated with the information collection, (3) for reasons other than to provide information to keep records for the government, or (4) as part of customary and usual business or private practices.

There is no change in the respondent burden.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a
description of the method used to estimate cost, which should include quantification of
hours, operational expenses (such as equipment, overhead, printing and support staff),
and any other expense that would have been incurred without this collection of
information. You may also aggregate cost estimates for Items 12, 13, and 14 in a single
table.

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.

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of
the OMB Form 83-I. Changes in hour burden, i.e., program changes or adjustments made
to annual reporting and recordkeeping hour and cost burden. A program change is the
result of deliberate Federal government action. All new collections and any subsequent
revisions of existing collections (e.g., the addition or deletion of questions) are recorded
as program changes. An adjustment is a change that is not the result of a deliberate
Federal government action. These changes that result from new estimates or actions not
controllable by the Federal government are recorded as adjustments.

N/A

16. For collections of information whose results will be published, outline plans for
tabulation and publication. Address any complex analytical techniques that will be used.
Provide the time schedule for the entire project, including beginning and ending dates of
the collection of information, completion of report, publication dates, and other actions.

No information collected from the form will be published.

17. If seeking approval to not display the expiration date for OMB approval of the
information collection, explain reasons that display would be inappropriate.

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 OMB clearance expiration date on the form.

18. Explain each exception to the certification statement identified in Item 19 “Certification
for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

There are no exceptions to the certification statement.