Certificate of Medical Examination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4339-1 Certificates of Medical Examination	Form and Instruction	Modified	Repair queued
supporting statement A certificates of medical examination revision 2022.docx	Supporting Statement A	Uploaded 2022-09-27	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
218023	Certificates of Medical Examination	Form and Instruction	Modified

ICR Details

OMB Control No: 0583-0167	ICR Reference No: 202206-0583-003
Status: Received in OIRA	Previous ICR Reference No: 202005-0583-002
Agency/Subagency: USDA/FSIS	Agency Tracking No:
Title: Certificate of Medical Examination
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 09/27/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	11/30/2022
Responses	1,250	800
Time Burden (Hours)	1,542	809
Cost Burden (Dollars)	0	0

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Abstract: to collect certificates of medical examination to determine whether or not an applicant for an FSIS Food Inspector, Consumer Safety Inspector, or Veterinary Medical Officer in-plant position meets the Office of Personnel Management (OPM) approved medical qualification standards and to collection information for requests for reasonable accommodations

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Authorizing Statute(s): US Code: 21 USC 451 Name of Law: Poultry Products Inspection Act
   US Code: 21 USC 1031 Name of Law: Egg Products Inspection Act
   US Code: 21 USC 601 Name of Law: Federal Meat Inspection Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 42991	07/19/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 58475	09/27/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Certificates of Medical Examination	4339-1, 4306-5	Certificate of Medical Examination (with Report of Medical History) ,   Medical Documentation for Employees Reasonable Accommodation Request

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ICR Summary of Burden

table that charts list of burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,250	800	0	450	0	0
Annual Time Burden (Hours)	1,542	809	0	733	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The Agency has increased the total burden estimate for the collection by 733 hours due an increase in hiring. The Agency also held more training on reasonable accommodation which caused an increase in the number of applications for reasonable accommodation. FSIS added 500 respondents for the FSIS Form 4339-1, and 200 respondents for the FSIS Form 4306-5.

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Annual Cost to Federal Government: $18,753

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/27/2022

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