Change Justification Request

OMB Control Number: 0583-0167

Title of Clearance: Certificates of Medical Examination

Agency Form Number affected by Change Worksheet: 4339-1 Certificate of Medical Examination (with Report of Medical History)

Summary of Non-substantive Changes: FSIS has made the following non-substantive, administrative changes to FSIS Form 4339-1 to clarify and more clearly explain the information needed from the respondents. There are no changes to the estimated burden. The items from the FSIS Form 4339-1 have been reworded and reordered as described below:

• Part B, #13 (page 11)

CURRENT

16. BLOOD PRESSURE/PULSE. Measure pulse and blood pressure. Agency Medical Qualification Standards indicate that systolic blood pressure greater than 155 and/or diastolic blood pressure greater than 95 may be disqualifying.

If blood pressure readings show signs of hypertension as described in the agency's Medical Qualification Standards, it will be necessary to take three (3) additional readings.

BP Reading 1 ____ Date ___________ Pulse Reading _______ Date _______

BP Reading 2 ____ Date ___________ (Take this additional reading if systolic and/or diastolic are above established standards on Reading 1.)

BP Reading 3 ____ Date ___________ (Take this additional reading if systolic and/or diastolic are above established standards on Reading 1.)

BP Reading 4 ____ Date ___________ (Take this additional reading if systolic and/or diastolic are above established standards on Reading 1.)

CHANGED TO

16. BLOOD PRESSURE/PULSE. Measure pulse and blood pressure. Agency Medical Qualification Standards indicate that systolic blood pressure greater than 155 and/or diastolic blood pressure greater than 95 may be disqualifying.

BP Reading 1 ______ Date ___________ Pulse Reading _______ Date _______

If blood pressure readings show signs of hypertension as described in the agency’s Medical Qualification Standards, please take three (3) additional, serial readings on three different days.

BP Reading 2 ______ Date ___________ (Take this additional reading if systolic and/or diastolic are above 155/95 on Reading 1.)

BP Reading 3 ______ Date ___________ (Take this additional reading if systolic and/or diastolic are above 155/95 on Reading 1.)

BP Reading 4 ______ Date ___________ (Take this additional reading if systolic and/or diastolic are above 155/95 on Reading 1.)

• Part B, #16 (page 11)

CURRENT

16. COMMUNICABLE OR CONTAGIOUS DISEASE.

Please administer the following Tuberculin test: ______________________

Date administered: _____________ Date read: _____________ Induration: _______ (measurement in mm) _______

Other results: ___________________________________________________________________

CHANGED TO

16. COMMUNICABLE OR CONTAGIOUS DISEASE.

Administer a Tuberculin test and show results below. [NOTE: If there is any history of TB, including a positive skin test for TB or a BCG vaccination, please also perform an X-ray to determine if the individual has active TB or residual damage from TB, and note results below.]

Name of Tuberculin test administered: ______________________

Date administered: _____________ Date read: _____________ Induration: _______ (measurement in mm) _______

Other results: ___________________________________________________________________

• Part C, #23 (page 13)

CURRENT

23. PERIPHERAL VISION. Any abnormalities? Yes No (If yes, please explain.)

Note peripheral visual fields: __________ degrees temporally __________ degrees nasally.

______________________________________________________________________

CHANGE TO

23. PERIPHERAL VISION. Please measure peripheral visual fields. Degrees temporally: _____ Degrees nasally: _____

Any abnormalities? Yes No (If yes, please explain.)

______________________________________________________________________

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