Fillable Printable SF 3112
Fillable Printable SF 3112
SF 3112
Form Approved:
OMB No. 3206-0228
Documentation in Support of
Disability Retirement Application
This package contains the forms applicants for disability retirement from civilian Federal service need to complete.
You should have received with this package a pamphlet entitled: Information About Disability Retirement. If you did
not receive the information pamphlet, ask your agency to give you one. This package contains the following forms:
Standard Form 3112A, Applicant's Statement of Disability, Standard Form 3112B, Supervisor's Statement, Standard
Form 3112C, Physician's Statement, Standard Form 3112D, Agency Certification of Reassignment and
Accommodation Efforts, and Standard Form 3112E, Disability Retirement Application Checklist.
You should keep one copy each of the completed forms for your own records. Your agency will send the originals of
each form to the Office of Personnel Management (OPM). You must obtain the evidence that will enable OPM to
decide that your disease or injury is so severe that you can no longer perform useful or efficient service, or that you
have a medical condition that requires restrictions from critical duties of your job.
You can help speed the processing of your application. Make sure all the information requested on the forms is
provided. Put a copy of your position description with the forms you give your doctor(s). See that the information you
submit contains diagnosis, prognosis, and a treatment plan dated no more than 60 days before the date your
application is filed. Although we accept all medical evidence about your disease or injury, current evidence provides
the best support of your application.
If you are applying for disability retirement under the Federal Employees Retirement System (FERS) or the
Civil Service Retirement System (CSRS) with offset service, you must document that you have applied for Social
Security disability benefits. The application receipt or award notice that you receive when you apply for Social
Security benefits should be attached to your application. Your application cannot be completely processed without
this information. Important: If Social Security awards you benefits, your payments from OPM must be reduced
starting on the date the Social Security award started. Since this may result in an overpayment of OPM benefits, you
should not spend any of the money from Social Security until your annuity from OPM has been reduced and OPM
has billed you for any overpayment. OPM is required by law to collect any annuity overpayment. If any or all of the
overpayment cannot be repaid, OPM may have to start debt collection procedures.
If you are not separated from Federal Service, return all the completed forms and associated documents to your
agency's personnel office. Your personnel office will assemble your disability retirement application package and
send it to OPM. Please follow up with your agency to be sure they send your application to OPM.
If you have been separated from Federal service for more than 31 days, you need to give each form to the
appropriate individual and ask that the completed forms be returned to you so you can assemble your disability
retirement application package yourself and send it to OPM at:
U.S. Office of Personnel Management
Retirement Operations Center
P.O. Box 45
Boyers, PA 16017-0045
OPM must receive your application not more than one year after the date you separated from your position. If you are
unable to get all the information requested, do not delay submitting your Standard Form 3112A to OPM. See the
accompanying pamphlet for an explanation of exceptions.
Standard Form 3112
7540-01-385-7215
Revised May 2011
3112-103
Previous edition is usable
Applicant's Statement of Disability
Civil Service
In Connection With Disability Retirement Under the Civil Service Retirement System or
Federal Employees
Retirement System
the Federal Employees Retirement System
Retirement System
A copy of this completed form must accompany the Supervisor's Statement you give
your supervisor(s).
Form Approved:
OMB No. 3206-0228
3.
Social security number
1. Name (last, first, middle)
2.
Date of birth (mm/dd/yyyy)
7a.
What accommodations have you requested from your agency?
7b.
Has your agency been able to grant your request? (Attach an explanation or any documentation that you have regarding accommodation.)
Yes
6.
Describe any other restrictions of your activities imposed by your disease or injury.
5.
Describe how your disease(s) or injury(ies) interferes with performance of your duties, your attendance, or your conduct.
4.
Fully describe your disease(s) or injury(ies.) We consider only the diseases and/or injuries you discuss in this application.
No
7c.
What is your current status with your agency?
In pay status; and working without accommodation. In leave without pay status.*
In pay status; and working with accommodation.
Separated from service*
*If you are currently in a leave without pay status or separated from service, what job(s), if any, have you performed since going into this status?
Please explain the physical and/or mental requirements for this (those) job(s).
8.
Give the approximate date you became disabled for your
position (mm/yyyy).
9. Have you been
hospitalized for your
disease or injury as
described in item 4?
10. Give date of most recent hospitalization.
From (mm/yyyy) To (mm/yyyy)
Yes No
11.
Notice for FERS and CSRS Offset Applicants ONLY
Application for disability retirement under FERS or CSRS Offset requires an application for Social Security Disability Benefits. Final
processing at OPM cannot be completed without a copy of your Social Security application receipt or award notice.
11a. Have you applied for disability benefits from the Social Security
Administration?
11b.
Is the application receipt or award notice attached?
Yes No Yes No
7540-01-385-7215
3112-103
Standard Form 3112A
U.S. Office of Personnel Management
Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous edition is usable
12. List physician(s), (name(s), address(es), and dates of treatment) from whom you plan to request Physician's Statements (SF 3112C). Attach an
additional sheet if you wish to list more physicians.
I certify that all statements made above are true to the best of my knowledge and
belief. I give my permission for the release of information about my service and
medical condition(s) (i.e., disease or injury) to authorized agency and OPM officials.
I have read and understand all of the information provided in the instructions to
this application.
Applicant's Consent and Certification
WARNING: Any intentionally false statement in
this application 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 U.S.C. 1001)
Signature (Do not print)
Date (mm/dd/yyyy)
Privacy Act Statement
Name Address Date of Treatments
13.
Daytime telephone number
( )
Email address
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and by the Federal
Employees Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly
associated with your application for Federal benefits, to obtain additional information if necessary, to determine and allow present or
future benefits, and to maintain a uniquely identifiable claim file. The 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 in order 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. 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. Executive Order 9397
(November 22, 1943) authorizes the use of the Social Security Number. Furnishing the data requested is voluntary, but failure to do so
will delay or prevent action on the retirement application.
Public Burden Statement
We estimate this form takes an average 30 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
(3206-0228), Washington, D.C. 20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and
you are not required to respond, unless this number is displayed.
Reverse of Standard Form 3112A
Revised May 2011
3112-103
PRINT
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Supervisor's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System
Civil Service
and the Federal Employees Retirement System
Federal Employees
Retirement System Retirement System
This form should be completed by the immediate supervisor
or someone who is in a position to observe the applicant on a regular basis.
Form Approved:
OMB No. 3206-0228
Instructions
All sections of this form must be completed properly.
Failure to do so will delay the processing of the disability
application at OPM.
The employee identified in Section A has indicated that he or
she intends to apply for disability retirement. The applicant's
signature on the "Applicant's Statement" authorizes his or her
immediate supervisor (or a supervisor who was and is in a
position to observe the applicant on a regular basis) to provide
the information and documentation requested. The immediate
supervisor is asked to provide information about the applicant's
job, performance, attendance, and conduct.
If you need more space in any section, attach a separate sheet
and indicate that an attachment is provided.
The following definitions apply to the terms used in the
Supervisor's Statement.
z
"Less than fully successful performance" means performance
of an employee which fails to meet established performance
standards in one or more critical elements of the employee's
position or the equivalent level for a position not under CFR
430.
z "Critical element" means a component of an employee's job
that is of sufficient importance that performing below the
minimum standard established by management requires
remedial action, such as denial of within-grade increase, and
may be the basis for reducing the grade level or removing the
employee.
z "Unacceptable attendance" means absence from work which
is too frequent, unpredictable, or lengthy to allow the job to be
done.
z
"Unsatisfactory conduct" means conduct for which an
employee may be removed or disciplined for cause under
adverse action procedures. (For example, discourteous
conduct to the public, behavior which poses a threat to the
life, health, safety, or well-being of co-workers, subordinates,
or the public.)
z "Accommodation" means an adjustment made to a job and/or
work environment that enables a qualified handicapped person
to perform the duties of that position. Reasonable accommo-
dation may include modifying the worksite, adjusting the
work schedule, restructuring the job, acquiring or modifying
equipment or devices, providing interpreters, readers or
personal assistants, and reassigning or retraining employees.
z
"5 CFR 531.409(d)" is the regulation that provides for a
waiver of the requirements for determination of an employee's
level of competence in certain cases when the employee was
in duty status for less than 60 days during the 52 calendar
weeks before a within-grade increase would be due.
After completing and certifying this form and attaching the
appropriate documentation, you should return the original to the
employee or to your personnel office according to instructions
and practices in your agency. In either case, a copy must be given
to the employee. Please do not send the form directly to OPM
unless OPM specifically requested you to do so.
If necessary, you may be contacted by OPM for additional
information or clarification.
Section B - Information About Employee's Performance
(See instructions above)
Section A - Applicant Identification
1. Name (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number
1. Title of position of record. (Attach a copy of position description and current performance standards.
If available, attach a copy of the latest performance appraisal.)
2. Date of entry into position
(mm/dd/yyyy)
3. Is performance less than fully successful in any critical element of position?
Yes, complete items 4 - 6 of this section. No, go to Section C.
No
Yes
Period the increase or award covered.
From (mm/yyyy) To (mm/yyyy)
5. After the date in item 4, has the employee received a within-grade step
increase or an award based on performance of a critical element?
4. Show the approximate date (mm/yyyy)
that unacceptable performance or the
inability to do the job began.
5a. Was within-grade
increase granted under 5
CFR 531.409 (d)? (see
instructions)
Yes No
Standard Form 3112B
U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
3112-103
Original - To OPM Through Agency Channels
6. Identify any critical element(s) of the position which employee does not perform successfully or at all. Explain the deficiencies you observed.
Attach supporting documentation such as notice to the employee that performance is less than fully successful or physician's recommendation
regarding medical restrictions.
Section C - Information About Employee's Attendance
1. Has employee stopped coming to work?
No Yes, how long is absence expected to continue (if known)?
2. Is employee's attendance unacceptable for continuing in current position?
No
Yes, attendance stopped or became unacceptable on (mm/yyyy):
Explain the impact of employee's absence on your work operations. 3.
Annual Sick LWOP
4. How many hours of leave has employee used for apparent medical reasons since date in item
C2? (Attach copies of medical information on which you based your decision to approve
Enter Leave
leave, leave records, records of contact with or notices to employee. Include as much
Hours Used
information as possible about specific reasons for leave use.)
Section D - Information About Employee's Conduct
1. Is employee's conduct unsatisfactory?
Yes, conduct became unsatisfactory on (mm/yyyy):
No, go to Section E.
Section E - Accommodation and Reassignment
2. Describe how conduct is unsatisfactory (attach supporting documentation, such as notice to employee of proposed adverse action).
(Consult with agency Coordinator for Employment of the Handicapped)
1. What efforts have been made to accommodate the employee in current position?
2. Has employee been reassigned to a new permanent position? (If yes, to what position and when?)
3. Has employee been reassigned to "light duty"
or a temporary position?
No
Yes, to on (mm/yyyy):
No, go to Section F. Yes
4. Describe the reason for temporary nature of assignment and length of time the employee is expected to occupy the position.
Section F - Supervisor's Certification
1. How long have you supervised the employee?
2d. Supervisor's office mailing address
2. I certify that all statements made on this Supervisor's
Statement are true to the best of my knowledge and belief.
2a. Supervisor's signature
2c. Date (mm/dd/yyyy)
2e. Supervisor's daytime telephone number (including area code)
2b. Supervisor's name (type or print legibly)
2f. Email address
3112-103
Reverse of Standard Form 3112B
Revised May 2011
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Physician's Statement
In Connection With Disability Retirement Under the Civil Service Retirement System
Civil Service Federal Employees
Retirement System
and the Federal Employees Retirement System
Retirement System
Applicant must attach a copy of the most current position description
Form Approved:
OMB No. 3206-0228
Section A - Identifying Information and Consent
(to be completed by applicant)
1. Applicant's name (last, first, middle)
2. Date of birth (mm/dd/yyyy)
3. Social security number
If you are currently employed by your agency or
separated for less than 30 days, enter exact name
and address including the name of the person or
office in your employing agency
where this information should be mailed.
4. Enter exact name and address (including ZIP Code).
If you have been separated from your
employing agency for 31 days or more
provide your current home address.
Applicant's Consent to Release
Medical Information
5. I authorize the release to the Office of Personnel Management and my employing agency of any
and all information or records connected with my disability retirement application.
Signature (do not print) Date (mm/dd/yyyy)
Privacy Act and Public Burden Statements
Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, title 5, U.S. Code) and the Federal Employees
Retirement law (Chapter 84, title 5, U.S. Code). The information you furnish will be used to identify records properly associated with your
application for Federal benefits, to obtain additional information if necessary, to determine and allow present or future benefits, and to maintain a
uniquely identifiable claim file. The 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 in order 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. 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. Executive Order 9397 (November 22, 1943) authorizes the use of the Social Security Number. Furnishing the
data requested is voluntary, but failure to do so will delay or prevent action on the retirement application.
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 (3206-0228), Washington, DC
20415-3430. The OMB number, 3206-0228, is currently valid. OPM may not collect this information, and you are not required to respond, unless
this number is displayed.
Section B - Medical Documentation (to be completed by physician)
Instructions
The individual identified above is requesting medical documentation that will be evaluated, along with non-medical documentation,
in connection with his or her application for disability retirement from Federal Government service. Please include all objective
findings and reports concerning the individual's condition. This documentation may also be used in determining his or her eligibility
for reassignment to a position that he or she is medically able to perform. A copy of his or her position description is attached for
your information.
z
Please provide the medical documentation requested under "Medical Documentation Requirements" on your letterhead
stationery. It is important that you respond to every item listed. Enter the item number of the information requested and
provide your response. If an item is not applicable to the applicant's medical condition, enter "Not Applicable." Include in
your statement the identifying information in Section A, items 1 through 3, above. Your failure to provide complete infor-
mation will delay the processing of your patient's disability retirement application.
z
Enclose your report and any attachments in a sealed envelope marked "Medical Disability - Privileged - Private." Please make
sure copies of all medical reports referenced in your statement are included. Send the envelope to the address shown in item 4
above. You may, if you wish, give it directly to the applicant for delivery to the appropriate office.
Continued on reverse
3112-103 Standard Form 3112C
U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous edition is usable
Instructions (continued)
z
Please complete this statement within 2 weeks. Be sure to sign the report. Include your address and telephone number.
z
The applicant is responsible for any costs incurred in connection with providing this documentation.
Medical Documentation Requirements
You must provide the following information:
1. A comprehensive history of this patient's medical con-
dition(s). This must include detailed information regarding
the symptoms and history, past and current physical
findings, results of laboratory studies and therapy of this
condition(s). The medical documentation must contain
specific information to show why this patient is not able to
perform his or her duties. The medical documentation
should not be conclusory. Provide a discussion of patient
compliance with therapy, response to therapy, and plans for
future therapy. Also, provide copies of pertinent hospital-
ization summaries and operative reports.
2. Copies of reports of all applicable diagnostic laboratory
tests (e.g. hematologic, chemistry, electrophysiologic,
radiologic, nuclear medicine, etc.) In the case of psychiatric
disorders, provide the results of mental status examinations,
personality tests, test of cognitive function, educational
evaluation, neuropsychiatric tests, etc.
3.
Diagnosis of patient's condition(s). Preferably each
diagnosis should be found in the current publication
"International Classification of Disease". In the case
of psychiatric disorders, diagnostic titles and codes
from the DSM III(R) should be used.
4. An assessment of the degree to which the medical con-
dition(s) has or has not become static and an estimate of
the expected date of full or partial recovery or remission.
5. If restrictions have been placed on this patient's activities,
please state what they are, why they have been imposed,
and how long you expect these to be in effect.
General Information
Disability retirement determinations are made in accordance
with Federal retirement regulations. A person is entitled to
disability retirement benefits only when the information
submitted with the application shows that an employee is
unable to perform useful and efficient service because of
disease or injury (1) in the employee's current position or (2)
within a vacant position, in the same agency and commuting
area at the same grade or pay level and tenure, for which the
employee is qualified for reassignment. Useful and efficient
service means fully successful performance of the critical or
essential elements of the position (or the ability to perform at
that level) and satisfactory conduct and attendance.
Reverse of Standard Form 3112C
3112-103
Revised May 2011
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Agency Certification of Reassignment and Accommodation Efforts
In Connection With Disability Retirement Under the Civil Service Retirement System
Civil Service Federal Employees
Retirement System
and the Federal Employees Retirement System
Retirement System
Form Approved:
OMB No. 3206-0228
Instructions
The Coordinator for Employment of the Handicapped should
review the Applicant's Statement, the Supervisor's Statement,
the Physician's Statement, and any other relevant documen-
tation on file to determine if reasonable accommodation will
enable the employee to perform fully successful service in his
or her current position or whether a vacant position is available
in the agency, at the same grade or pay level in the same com-
muting area, for which the employee is qualified for reassign-
ment. Take special note of the Supervisor's Statement and
resolve any discrepancies between the information on that form
and this form. Telephone numbers for the applicant, the super-
visor, and the physician may be found on their respective
statements, should it be necessary to contact them for further
information.
If the employee is eligible to retire voluntarily, the employee
should be advised of that fact. In general there is no difference
in the payment to a disabled annuitant and an optionally retired
annuitant, nor are there Federal tax advantages for a disability
retiree.
All items must be completed. In items 4, 5, and 6, if you check
a box that requires additional explanation, please provide the
explanation and/or attachment. This will enable us to process
the application without delay.
Accommodation (item 4) - Guidance for determining reason-
able accommodations may be found in 29 CFR 1614.203(c).
The documentation supporting your response to item 4 must
include an assessment of the functional and environmental
factors related to the employee's inability to perform at the fully
successful level, unless there are no medical restrictions.
Reassignment (item 5) - Guidance related to reassignment of
an applicant for disability retirement is published in OPM's
"CSRS and FERS Handbook for Personnel and Payroll
Offices".
After completing and certifying this form, please attach the
appropriate documentation and return the original to the
employee or to your personnel office according to instructions
and practices in your agency. In either case, a copy must be
given to the employee. Please do not send the form directly to
OPM unless OPM specifically requested you to do so in this
case.
Your agency's obligation to continue to try to accomodate or
reassign the employee does not cease with the filing of this
certification. Your efforts should continue. If the accomm-
odation or reassignment situation changes after the original
filing of the certification, you must notify OPM of the changes.
OPM may contact you for additional information or
clarification.
1. Name of applicant (last, first, middle) 2. Date of birth (mm/dd/yyyy) 3. Social security number
To be completed by Coordinator for Employment of the Handicapped or other authorized agency official.
See instructions at the top of this page
4. Has reasonable effort for accomodation been made? (You must check one statement below.)
No, the medical evidence presented to the agency shows that accommodation is not possible due to severity of medical condition and the
physical requirements of the position. (Attach copies of all medical evidence supporting the statement and explain why conditions prohibit
accommodation. Also, provide a detailed statement of the physical requirements of the position.) Employees should be counseled concerning
the following: The fact that your agency has determined accommodation to be unavailable due to status of a medical condition or due to
restriction imposed by a physician does not guarantee that OPM will reach the same decisions about the approval of a disability retirement
application.
No, the employee's condition does not appear to require accommodation. Medical information presented to agency does not document a
disabling medical condition.
Yes, describe below accommodation efforts made, attach supporting documentation and provide narrative analysis of any unsuccessful
accommodation efforts.
Continued on reverse
Standard Form 3112D
Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices
Previous edition is usable
U.S. Office of Personnel Management
3112-103
Duplicate - Employee's Copy
5. Results of agency reassignment efforts (You must check one statement below.)
Reassignment is not necessary because employee's performance is fully successful and there are no medical restrictions which keep the
employee from performing critical duties or from attending work altogether.
Reassignment is not possible. There are no vacant positions at this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications standards.
The employee declined reassignment to a vacant position(s) in this agency at the same grade or pay level and tenure, within the same
commuting area, for which the employee meets minimum qualifications. (Attach a copy of any reassignment offers.)
The agency did not reassign the employee to the vacant position(s) in this agency, at the same grade or pay level and tenure within the same
commuting area, for which the employee meets minimum qualifications. The position(s) identified and reason(s) for non-assignment are shown
below.
Position Title Reason for Non-Reassignment or Non-Selection*
* If the employee's medical condition precludes reassignment to the position, attach documentation. If the reason for non-selection is intended
removal, attach a copy of the removal notice to the employee.
6. Is the employee currently occupying a temporary position?
No, the employee is occupying a permanent position.
Not applicable, the employee is no longer an employee of the agency.
Yes, state below the nature of these duties, the reason for the temporary status, and length of time the agency expects the employee to occupy
this position.
Certification by Coordinator for Employment of the Handicapped or other authorized agency official.
7.
I certify that this statement is true to the best of my knowledge and belief.
7a. Signature of responsible agency official
7b. Title of responsible agency official
7c. Date (mm/dd/yyyy)
7d. Name of responsible agency official (type or print legibly) 7e. Telephone number (including area code)
7f. Email address
Reverse of Standard Form 3112D
3112-103
Revised May 2011
PRINT
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Disability Retirement Application Checklist
For Disability Retirement Under the Civil Service Retirement System
and the Federal Employees Retirement System
Civil Service Federal Employees
Retirement System
(to be completed by employing agency)
Retirement System
Form Approved: OMB No. 3206-0228
3. Social security number 1. Name of applicant (last, first, middle) 2. Date of birth (mm/dd/yyyy)
4. Do available records show that the employee has at least 5 years of civilian service under the Civil Service Retirement System or at least 18 months
under the Federal Employees Retirement System?
Yes
No
5a. Show the date pay stopped or will stop. (mm/dd/yyyy)
Yes
5. Will employee remain in duty status?
No
6. Has employee ever received or made application for compensation 6b. Period compensation was received.
from the Department of Veterans' Affairs?
6a. Claim number
From (mm/yyyy) To (mm/yyyy)
Yes No
7a. Has the employee made application for disability benefits from
7b. Is the application receipt or award notice attached?
the Social Security Administration?
Yes
No
Yes No
8. Are the following documents attached (Indicate by "X" for each).
Not
Applicable
b. SF 3112A, Applicant's Statement of Disability
-
Employee's Performance Standards
-
Supporting documentation regarding employee's performance
-
Supporting documentation regarding employee's conduct
e. SF 3112D, Agency Certification of Reassignment and Accommodation Efforts
-
Supporting documentation of employee's non-reassignment or non-selection
g. Other:
FERS and CSRS
Offset Applicants
a. SF 2801 or SF 3107, Application for Immediate Retirement
c. SF 3112B, Supervisor's Statement
- Employee's Position Description
- Supporting documentation regarding employee's leave use
d. SF 3112C, Physician's Statement (or equivalent)
- Supporting documentation of Agency's accommodation efforts
f. Agency report of Federal medical examination (if one was made)
Yes No
7.
9. Has the supervisor stated the employee's performance is less than fully successful in any critical element of the position in Section B, SF 3112B?
(1) a copy of the employee's performance appraisal covering the employee's service prior to the date shown in Section B,
Yes,
item 5, of the Supervisor's Statement, and
(2) a copy of the performance appraisal covering service after that date, if available.
No
10. If the employee is temporarily at an address other than the one given 11. If the employee is unable to act on his own behalf, give the name
and address of the person acting for him or her. on SF 2801 or SF 3107, Section A (such as hospital, nursing home,
or with a relative), enter that address, including ZIP Code.
Agency Certification
13. Full Agency name and address (including ZIP Code)
12.
I certify that the information shown above accurately
reflects verified information in official records.
12a. Signature of Chief Personnel Officer or Designee
12b. Official title
14. List the full name and address of agency office and official to be
notified of OPM's determination (including telephone number and
area code).
12c. Email address
12d. Telephone number (incl. area code) 12e. Date (mm/dd/yyyy)
Check here if this address is the same as the address in item 13.
Standard Form 3112E
U.S. Office of Personnel Management Revised May 2011
CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable
3112-103
PRINT
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