Opm1530_2017_03

Form Approved:
OMB No. 3206-0162

Report of Medical Examination of Person Electing Survivor Benefits
To the applicant: Complete blocks 1 through 4 then sign your name in block 5.
1. Name (last, first, middle)

2. Date of Birth (mm/dd/yyyy

3. Social Security Number

4. Do you have any known significant impairment of health or disabling condition which in your opinion could cause death or shorten your normal life
expectancy?

No
Yes, If "yes," please explain -

e
Privacy Act Statement: Solicitation of this information is authorized by
the Civil Service Retirement law and Federal Employees Retirement
System (Chapter 83, title 5, U.S. Code and Chapter 84, title 5, U.S. Code).
The information you provide will be used to determine whether you may
elect a reduced annuity to provide survivor benefits for a person you
name having an insurable interest in you. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security number.
Furnishing the Social Security Number, as well as other information is
voluntary, but failure to do so may delay or prevent us from determining
if you are eligible to provide survivor benefits for the person you name.
5. In the presence of the physician sign your name
in ink as it appears on your retirement application.

Public Burden Statement: We estimate this form takes an average of 90
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, Retirement Services Publications Team (3206-0162), Washington,
DC 20415-001. The OMB Number 3206-0162 is valid. OPM may not collect this
information, and you are not required to respond, unless this number is
displayed.

Signature of applicant

Date

To the treating physician: You should examine the applicant to determine whether he or she is in good physical condition as can be determined from a
routine general medical examination. The Office of Personnel Management will use the information you provide in determining whether the applicant may
elect a survivor benefit under the Civil Service Retirement System or the Federal Employees Retirement System. If you need more space for any item(s) attach a
separate page. Include on each separate page the identifying information in items 1, 2, and 3 above.

Physical Findings
1. General appearance, including state of nutrition

2. Height
Feet

3. Weight

4. Blood Pressure

10. Mouth

Inches

5. Skin

11. Neck

6. Gait

12. Heart

7. Eyes
8. Ears
9. Nose

13. Lungs

(continued on the reverse side)

Office of Personnel Management
CSRS/FERS Handbook for Personnel and Payroll Offices

To be reproduced locally

OPM Form 1530
Revised March 2017
Previous edition is usable

14. Abdomen

15. Extremities

16. Reflexes

17. Nervous system

18. History of, or physical findings indicating, a metabolic disorder, blood dyscrasia, or other significant disorder. Indicate laboratory procedure results.

19. Any significant impairment of health or disabling condition not described above should be described here.

20. Conclusion

I certify that the statements made in this report are true to the best of my knowledge.
Signature of treating physician

Address (including Zip Code)

Name of treating physician (Type or print)

Date of examination (mm/dd/yyyy)

Reverse of OPM Form 1530
Revised March 2017