Reverse of RI 30-1
Revised February 2018
Important: Answer All Questions and Return Promptly
1. Have you recovered sufficiently to return to work?
Yes No
2.
Are you now employed, or have you been employed during the last 12 months (including
self-employment)? If yes, state below:
Yes No
Dates of Employment
From (mm/dd/yyyy) To (mm/dd/yyyy)
Hours
Per Day
Total
Earnings
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 Telephone number (including area code)
3.
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 Mailing address (including ZIP code)
Date (mm/dd/yyyy) Telephone number (Including area code)
Email address CSA claim number
Privacy Act Statement
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why OPM is requesting the information on this form. Authority: OPM is authorized to
collect the information on this form by Title 5, U.S. Code, Chapter 83, Section 8337(c) and Chapter 84, Section 8454. Purpose: OPM is requesting this information in order so
that we can determine if your disability annuity may continue. 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 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. 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, failure to supply all of the requested information will result in a
suspension of your disability annuity.
Public Burden Statement
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.
