Information Collection

Certificate of Medical Examination

IC 218023 under ICR 201810-0583-003 · OMB 0583-0167.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0583-0167 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FSIS Form 4339-1 Certificate of Medical Examination	Form and Instruction
FSIS Form 4339-1 Certificate of Medical Examination (with Report of Medic FSIS 4339-1 Certificate of Medical Examination (with Report of Medical History) .pdf	Form and Instruction

IC Title:

Certificate of Medical Examination

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 339

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FSIS Form 4339-1	Certificate of Medical Examination (with Report of Medical History)	FSIS 4339-1 Certificate of Medical Examination (with Report of Medical History) .pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title: Employee Medical File System (OPM/Govt-10)

FR Citation: 75 FR 35099

Number of Respondents: 500

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	750	750
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.