Justification Change Request 0583-0167

OMB Control Number: 0583-0167

Title of Clearance: Certificates of Medical Examination

Agency Form Number affected by Change Worksheet: 4339-1, 4630-8, 4306-5

Summary of Non-substantive Changes: Based on the U.S. Equal Employment Opportunity Commission’s public comment submitted to the 30-day Federal Register Notice on November 26, 2019, FSIS has made the following administrative changes to the forms:

1. FSIS Form 4339-1 Certificate of Medical Examination (with Report of Medical History)

This form was amended to clarify that it will only be used to collect medical information about applicants during the post-offer phase of hiring or to collect medical information about employees when job-related and consistent with business necessity. Also, the most current EEO statement has replaced the older version that was on the form, and the word “race,” which was inadvertently omitted previously, is now included.

2. FSIS Form 4630-8 Confidential Medical Information

This form number was changed from 4630-8 to 4630-7 and the following language was added:

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.

3. FSIS Form 4306-5 Medical Documentation for Employee’s Reasonable Accommodation Request

The following language was added:

AUTHORITY: The Food Safety and Inspection Service is authorized by Section 501 of the Rehabilitation Act, 29 U.S.C. § 791, to collect the information on this form.

PRINCIPAL PURPOSE(S): To facilitate the employee/applicant request for a reasonable accommodation. The requested information is required to establish that the employee/applicant has a covered disability, the functional limitations of the disability, and the need for reasonable accommodation.

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 Reasonable Accommodation Program.

DISCLOSURE: Disclosure is voluntary. However, Failure to fully complete the form or refusal to provide the requested documentation may lead to a breakdown in the reasonable accommodation process and could result in a determination that the employee/applicant is not entitled to reasonable accommodation.