Information Collection

Certificates of Medical Examination

IC 218023 under ICR 201910-0583-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Certificates 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
4306-5 Medical Documentation for Employee's Reasonable Accommod FSIS 4306-5 Medical Documentaion for Employees's Reasonable Accommodation Request_v11re508 .pdf	Form
4630-8 Confidential Medical Documentation FSIS 4630-8 CONFIDENTIAL MEDICAL DOCUMENTATION_v11re508.pdf	Form

IC Title:

Certificates 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	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
Form	4306-5	Medical Documentation for Employee's Reasonable Accommodation Request	FSIS 4306-5 Medical Documentaion for Employees's Reasonable Accommodation Request_v11re508 .pdf	Yes	No	Paper Only
Form	4630-8	Confidential Medical Documentation	FSIS 4630-8 CONFIDENTIAL MEDICAL DOCUMENTATION_v11re508.pdf	Yes	No	Paper Only

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: 800

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	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	800	300	0	500
Annual IC Time Burden (Hours)	809	24	35	750
Annual IC Cost Burden (Dollars)	0	0	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.