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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.