Form 4630-7 Confidential Medical Documentation

OMB Control Number 0583-0167
Expiration Date:

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0583-0167. The time
required to complete this information collection is estimated to average 15 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
U.S. DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

CONFIDENTIAL MEDICAL DOCUMENTATION
(To be completed by Health Care Provider)

INSTRUCTIONS: Your patient is an employee with the U.S. Department of Agriculture (USDA), Food Safety and Inspection Service
(FSIS) and has requested to receive donated leave from the Leave Bank Program for an extended absence due to a personal or
family medical emergency. Please provide the following medical information to your patient, including as much detail as possible
(Please refrain from using technical terms), so he or she can send it to [email protected] or fax to 202-720-5124.
Patient Name:

PART I - CURRENT EVALUATION, ANALYSIS AND TREATMENT
1. Medical reason leave is needed:

2. Nature of medical emergency:

3. Anticipated duration (start and end dates) of medical emergency::

4. If medical emergency is intermittent, describe duration and frequency:

PART II - CERTIFICATION
I certify that the absence or treatment noted above is necessary to return the patient to a healthy condition or to accommodate his/her
medical condition. The patient is unable to work, because of the reasons stated in Part I of this application. This application may also
apply to caring for a family member. An appropriate family member may apply on behalf of an incapacitated family member.
Name of Health Care Provider:

Phone Number:

Health Care Provider Signature:

FSIS Form 4630-7 (07/11/2019)

Health Care Provider Facility Address:

Email:

Fax Number:

Date:

AUTHORITY: The Food Safety and Inspection Service is authorized by Title 5, Code of Federal Regulations, Part 630, Subpart J, Leave
Bank Program, to collect the information on this form. Solicitation of this information is also authorized by Section 6367 of Title 5, United
States Code, regarding determination if an individual is eligible to receive donated leave due to a personal or family medical emergency.
PRINCIPAL PURPOSE(S): To obtain medical information from FSIS employees to assist in determining eligibility to receive donated
leave from the leave bank. Additional potential uses of this information include using it to ensure fair and consistent treatment of
employees and to adjudicate claims of discrimination under the Rehabilitation Act of 1973, as amended.
ROUTINE USE(S): The information will be used by and disclosed to FSIS personnel and contractors or other agents who need the
information to implement and maintain the Leave Bank Program.
DISCLOSURE: Disclosure is voluntary. However, failure by an employee to provide the information may result in a denial to become a
leave recipient.

FSIS Form 4630-7 (07/11/2019)