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 Under the Civil Service Retirement System	Form and Instruction	Modified	Repair queued
E8-5659.pdf	Supplementary Document	Uploaded 2020-09-17	Repair queued
OPM1530_2020_10_Revised.pdf	Supplementary Document	Uploaded 2020-09-17	Repair queued
OPM1530_2017_03_MarkUp.pdf	Supplementary Document	Uploaded 2020-09-17	Repair queued
2020-17685.pdf	Supplementary Document	Uploaded 2020-09-17	Repair queued
2020-07633.pdf	Supplementary Document	Uploaded 2020-09-17	Repair queued
OPM1530_OMBSupportStmt_2020_09_28.docx	Supporting Statement A	Uploaded 2020-09-28	Repair queued

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

ICR Details

OMB Control No: 3206-0162	ICR Reference No: 202009-3206-002
Status: Received in OIRA	Previous ICR Reference No: 201703-3206-003
Agency/Subagency: OPM	Agency Tracking No: OPM 1530
Title: Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/30/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	01/31/2021
Responses	500	500
Time Burden (Hours)	750	750
Cost Burden (Dollars)	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. We have updated the display of OMB nomenclature and made editorial changes to the Privacy Act Statement.. 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:
	85 FR 20532	04/13/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 49398	08/13/2020
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 Under CSRS

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	500	0	0	0	0
Annual Time Burden (Hours)	750	750	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:

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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? No

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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: 09/30/2020

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