RI 30-1 Request to Disability Annuitant for Information on Physi

Form Approved:
OMB No. 3206-0143

United States
Office of Personnel Management
Medical Call-Up Review Team
P.O. Box 45
Boyers, PA 16017
Date (mm/dd/yyyy)

Claim number

CSA
Date of birth (mm/dd/yyyy)

This Questionnaire Must Be Returned Within 90 Days for Your Disability Annuity to Continue
You were approved for disability retirement on the basis of the documentation you provided. The retirement system
requires a periodic check of disability annuitants to determine if the condition on which they retired continues to be disabling.
The information listed below is needed to comply with that requirement. The Office of Personnel Management (OPM) will
not pay for any expenses that you may incur in acquiring this documentation.
In order for us to evaluate whether or not you are entitled to continuation of disability annuity payments, please have your
physician or treating medical facility provide the following information on the physician's or facility's letterhead signed by
the treating physician:
1.

Current clinical findings from a recent physical examination, including the results of any diagnostic tests that have been
performed.

2.

An update since your retirement of the specific medical condition(s) which required you to retire. This should include a
current prognosis.

3.

An assessment, including a current prognosis, of the specific medical condition(s) and plans for future treatment.

4.

A clinical assessment of risk of injury or hazard to self and others which would arise from the performance of essential
duties of a position similar to the one from which you retired.

Also, answer questions 1, 2, and 3 on the reverse side of the form, sign Item 4 and mail the documents to the above address.
Failure to answer all questions may delay processing of your case. If the information shows that you are still disabled for your
former position, your annuity will be continued without further correspondence from us. If our review requires additional
information, you will be notified.
If we do not receive this questionnaire and the requested medical documentation within 90 days, we may suspend your
annuity payments until the requested information is received. If you are unable to respond within the time limitation or if we
can be of further assistance to you, please contact the Medical Call-Up Review Team at 724-794-7799 (TTY: 724-794-3392).
Retirement Operations

Previous editions are not usable.

RI 30-1
Revised November 2016

Important: Answer All Questions and Return Promptly
1.

Have you recovered sufficiently to return to work?

2.

Are you now employed,or have you been employed during the last 12 months (including
self-employment)? If yes, state below:
Dates of Employment

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Hours
Per Day

Total
Earnings

Yes

No

Yes

No

Name and Address of Employer
(including ZIP code)

State type of position and nature of duties (attach a copy of the position description if available).

Inquiry may be made of your present employer to verify your records of employment and medical condition.
Name of immediate supervisor

3.

Telephone number (including area code)

Have you ever received or made application for compensation from the U.S. Department of
Labor, Office of Workers' Compensation Programs, under the Federal Employee's
Compensation Act?

Yes

No

If yes, state your Compensation claim number and the period(s) for which you received compensation.
Compensation claim number

From (mm/dd/yyyy)

To (mm/dd/yyyy)

Warning: Any intentionally false statement or willful misrepresentation relative thereto is a violation of the law punishable by a fine
of not more than $10,000 or imprisonment of not more than 5 years, or both. (18 USC 1001)
4.

I hereby affirm that the above answers are true to the best of my knowledge and belief.

Signature

Date (mm/dd/yyyy)

Email address

Mailing address (including ZIP code)

Telephone number (Including are code)

CSA claim number

Privacy Act and Public Burden Statements
Title 5, U.S. Code, authorizes solicitation of this information. The data you furnish will be used to determine whether your disability annuity can continue. This information may
be shared and is subject to verification, via paper, electronic media, or through the use of computer matching programs, with national, state, local or other charitable or social
security administrative agencies to determine and issue benefits under their programs, to obtain information necessary for determination or continuation of benefits under this
program, or to report income for tax purposes. It may also be shared and verified, as noted above, with law enforcement agencies when they are investigating a violation or
potential violation of civil or criminal law. Providing this information is voluntary; however, failure to supply all of the requested information will result in a suspension of your
disability annuity.
We estimate this form takes an average 60 minutes per response to complete, including the time for reviewing instructions, getting the needed data, and reviewing the completed
form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM),
Retirement Services Publications Team (3206-0143), Washington, DC 20415-0001. The OMB Number 3206-0143 is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.

Reverse of RI 30-1
Revised November 2016