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Report Of Medical Examination Of Person Electing Survivor Benefit Form. This is a Official Federal Forms form and can be use in OPM US Office Of Personnel Management.
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Form Approved: OMB No. 3206-0162 Report of Medical Examination of Person Electing Survivor Benefits Under the Civil Service Retirement System 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 Privacy Act Statement: Solicitation of this information is authorized by the Civil Service Retirement law (Chapter 83, 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. Signature of applicant 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 20415-3430. 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. 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. 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 5. Skin Inches 3. Weight 4. Blood pressure 10. Mouth 11. Neck 6. Gait 12. Heart 7. Eyes 8. Ears 9. Nose 13. Lungs (Continued on the reverse side) To be reproduced locally OPM Form 1530 Revised April 2011 Office of Personnel Management CSRS/FERS Handbook for Personnel and Payroll Offices Previous edition is usable. American LegalNet, Inc. www.FormsWorkFlow.com 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 April 2011 American LegalNet, Inc. www.FormsWorkFlow.com