Certificate of Medical Examination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FSIS Form 4339 Certificate of Medical Examination	Form and Instruction	New	Available
FSIS_certificate of medical examination supporting statement A_v.2.docx	Supporting Statement A	Uploaded 2015-11-16	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218023	Certificate of Medical Examination	Form and Instruction	New

ICR Details

OMB Control No: 0583-0167	ICR Reference No: 201508-0583-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: USDA/FSIS	Agency Tracking No:
Title: Certificate of Medical Examination
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/01/2015
	Date Received in OIRA: 09/25/2015
Terms of Clearance: Forms must display the OMB control number and expiration date.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved
Responses	500	0	0
Time Burden (Hours)	750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: to collect certificates of medical examination to determine whether or not an applicant for an FSIS Food Inspector, Consumer Safety Inspector, or Veterinary Medical Officer in-plant position meets the Office of Personnel Management (OPM) approved medical qualification standards

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Authorizing Statute(s): US Code: 21 USC 601 Name of Law: Federal Meat Inspection Act
   US Code: 21 USC 451 Name of Law: Poultry Products Inspection Act
   US Code: 21 USC 1031 Name of Law: Egg Products Inspection Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 28220	05/18/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 56438	09/18/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certificate of Medical Examination	FSIS Form 4339	Certificate of Medical Examination (with Medical History)

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	500	0	0	500	0	0
Annual Time Burden (Hours)	750	0	0	750	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection resulting in a program change of 750 burden hours.

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Annual Cost to Federal Government: $9,500

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/25/2015

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