Certificate of Medical Examination

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.