RI30-001_2021_01

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United States
Office of Personnel Management
Medical Call-Up Review Team
P.O. Box 45
Boyers, PA 16017

OMB Approval 3206-0143

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 you are entitled to continuation of disability annuity payments, please have your physician,
or other licensed health practitioner provide the following information on their letterhead.
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 this 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; hearing impaired users should
utilize the Federal Relay Service by dialing 711 or their local communications provider to reach a Communications Assistant.
Retirement Operations

Previous edition is not usable.

RI 30-1
Revised April 2024

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 area code)

CSA claim number

Privacy Act Statement
Authority: OPM is authorized to collect this information under 5 U.S.C. Chapter 83, Section 8337(c) and Chapter 84, Section 8454. Purpose: OPM uses this information to determine whether you
remain eligible to receive disability retirement benefits. Routine Uses: The information requested on this form may be shared externally as a "routine use" to other Federal agencies and third-parties
when it is necessary to process your election. For example, OPM may share your information with other Federal, state, or local agencies and organizations to determine benefits under their programs, to
obtain information necessary for determination or continuation of benefits under this program, or to report income for tax purposes. OPM may also be share your information with law enforcement
agencies if it becomes aware of a violation or potential violation of civil or criminal law. A complete list of the routine uses can be found in the OPM/CENTRAL 1 Civil Service Retirement and
Insurance Records system of records notice, available at www.opm.gov/privacy. Consequences of Failure to Provide Information: Providing this information is voluntary. However, if you do not
provide the requested information, OPM may be unable to determine whether you remain eligible for disability retirement benefits. As a result, your disability annuity may be suspended.

Public Burden Statement
The public reporting burden to complete this information collection is estimated at 60 minutes per response, including for reviewing instructions, searching data sources, gathering and maintaining the
data needed, and the completing and reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays
a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection information, including suggestions for reducing this burden to the Office of
Personnel Management, RS Publications Team at [email protected]. Current information regarding this collection of information – including all background materials -- can be found at
https:/www.reginfo.gov/public/do/PRAMain by using the search function to enter either the title of the collection or OMB Control Number 3206-0143.

Reverse of RI 30-1
Revised April 2024