4339-1 Certificate of Medical Examination (with Report of Medic

OMB Control Numer: 0583-0167
Expiration Date: 11/30/2022
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 90 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.
UNITED STATES DEPARTMENT OF AGRICULTURE
FOOD SAFETY AND INSPECTION SERVICE

CERTIFICATE OF MEDICAL EXAMINATION (with REPORT OF MEDICAL HISTORY)

(This information is for official and medically confidential use only and will not be released to unauthorized persons)

AUTHORITY: The Food Safety and Inspection Service is authorized by Title 5, Code of Federal Regulations, Part 339, Medical Qualification Determinations, to collect the information
on this form. Solicitation of this information is also authorized by Section 552a of Title 5, United States Code, regarding records maintained on individuals; Section 3301 of Title 5,
United States Code, regarding determination as to an individual's fitness for employment with regard to age, health, character, knowledge and ability. The information you provide will be
used to determine your medical qualifications for Federal employment.
PRINCIPAL PURPOSE(S): To obtain medical information from FSIS current and prospective employees to assist in making a determination of medical fitness for duty. Additional
potential uses of this information include using it to ensure fair and consistent treatment of employees and job applicants and to adjudicate claims of discrimination under the
Rehabilitation Act of 1973, as amended. This form is only 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.
DISCLOSURE: Disclosure is voluntary. However, failure by a candidate to provide the information may result in a delay of appointment and/or withdrawal of tentative offer of
employment. Failure of an employee to provide the information may result in removal from Agency duties and/or disciplinary actions, up to and including termination.
PRIVACY ACT STATEMENT: In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that Section 3301 of Title 5 to the US Code
authorizes collection of this information. The primary use of this information is to determine medical suitability of persons for service or assignments, report medical conditions required
by law, and aid in preventive health care. The information becomes part of the Employee Medical Folder, which is maintained and protected in accordance with OPM regulations 5 CFR
293, Subpart E. These records are also protected by the Privacy Act of 1974, 5 U.S.C. 552a and are covered by OPM/GOVT-10, Employee Medical File System Records. The social
security number is requested in order to more accurately identify and retrieve health care records of individuals. Providing the requested information is voluntary but failure to do so may
result in the Agency's inability to process application for employment.
NON-DISCRIMINATION STATEMENT: The U.S. Department of Agriculture (USDA) prohibits discrimination in all employment activities on the bases of race; color; religion; national
origin; age; sex (including pregnancy, gender identity, and sexual orientation); disability; political beliefs; marital, familial or parental status; genetic information; or reprisal. Persons with
disabilities who require alternative means for communication (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TDD). To initiate a
complaint of employment discrimination, contact the Food Safety and Inspection Service Civil Rights Staff within 45 days from the day the discrimination occurred, at USDA, FSIS, Office
of the Administrator, Civil Rights Staff, 5601 Sunnyside Avenue, Building 1, Room 2260, Mail Stop 5261, Beltsville, Maryland 20705, 1 (800) 269-6912 (toll free) or (301) 504-7755
(Voice and TDD). Employment complaints can also be initiated electronically at: https://usda-efile.icomplaints.com/efile-usda-prod/login/. USDA is an equal opportunity provider and
employer.

NOTE TO THE APPLICANT/EMPLOYEE
Please complete Part A of this form (pages 1-8) and take it with you to your appointment for a medical physical examination. Please have
your doctor(s) complete the medical exam portions (Parts B, C and D), sign and date each of the three parts to certify completion of the
medical exam, and forward it directly to us.
Waiver of medical standards may be considered in conjunction with a complete health and safety review. Please contact the hiring agency/
employing agency directly if you wish to request reasonable accommodation. A reasonable accommodation is any change to a job, the work
environment, or the way things are usually done that enables an individual with a disability to apply for a job, perform job duties or receive
equal access to job benefits.

PART A. TO BE COMPLETED BY THE APPLICANT/EMPLOYEE
1. LAST NAME, FIRST NAME, MIDDLE NAME

2. SOCIAL SECURITY NUMBER

4a. HOME ADDRESS (Street, Apartment No., City, State and ZIP Code

3. TODAY'S DATE (mm/dd/yy)

4b. HOME TELEPHONE (Include Area Code)

4c. EMAIL ADDRESS

5a. Date of Birth

5b. Sex:

Male

Female

(mm/dd/yy)

6. CHECK ONE:

APPLICANT

EMPLOYEE

7. MEDICAL EXAMINATION LOCATION ADDRESS (Include Zip Code), AND TELEPHONE NUMBER

FSIS FORM 4339-1 (05/20/2020)

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LAST NAME, FIRST NAME, MIDDLE INITIAL

8. CURRENT MEDICATIONS (Prescription and over-the-counter)

DATE

NAME OF MEDICATION

REASON FOR MEDICATION

Please indicate the date when your prescription began.
List your dosage amounts and identify reason for taking
each medication and number of times taken during the day.
DOSAGE

FREQUENCY SIDE EFFECTS EXPERIENCED

9. ALLERGIES (Including environmental, medicine, latex or other substances)

10. HAVE YOU HAD SURGERY OR BEEN HOSPITALIZED IN THE LAST 10 YEARS?

Yes

No

(IF YES, PLEASE COMPLETE.)
Indicate Month/Year of Surgery/Hospitalization (make sure type of surgery is included)

Reason for Surgery/Hospitalization

11. HAVE YOU SEEN A DOCTOR IN THE PAST 12 MONTHS FOR ANY MEDICAL PROBLEM?

Yes

No

(IF YES, PLEASE DESCRIBE.)

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LAST NAME, FIRST NAME, MIDDLE INITIAL

REVIEW OF SYSTEMS
Mark each item "YES" or "NO". Every item marked "YES" must be fully explained, including dates (mo/yr) and treatment.

12. MUSCULOSKELETAL
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Painful shoulder, elbow or wrist (e.g. pain, dislocation, etc.)
b. Recurrent back pain or any back problem
c. Numbness or tingling
d. Loss of finger or toe
e. Foot trouble (e.g., pain, corns, bunions, etc.)
f. Impaired use of arms, legs, hands, or feet
g. Swollen or painful joint(s)
h. Knee trouble (e.g., locking, giving out, pain or ligament injury, etc.)
i. Any knee, foot, hip, shoulder or wrist surgery
j. Any need to use corrective devices such as prosthetic
devices, knee brace(s), back support(s), lifts or orthotics, etc.
k. Bone, joint, or other deformity
l. Plate(s), screw(s), rod(s) or pins(s) in any bone
m. Broken bone(s) (cracked or fractured)
n. Herniated disc
o. Repetitive motion symptoms (e.g., carpal tunnel, rotator cuff
or tennis elbow)
p. Other musculoskeletal problems

13. RESPIRATORY
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Tuberculosis
b. Positive skin test for TB
c. Lived with someone who had tuberculosis
d. Coughed up blood
e. Asthma or any relating problem (indicate whether it is a current
condition and/or childhood condition
f. Shortness of breath
g. Chronic bronchitis
h. Chronic wheezing or problems with wheezing
i. Been prescribed or used an inhaler
j. A chronic cough or cough at night
k. Chronic sinusitis
l. Hay Fever
m. Chronic or frequent colds
n. Collapsed lung
o. Emphysema or chronic obstructive pulmonary disease
p. Other respiratory problems
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LAST NAME, FIRST NAME, MIDDLE INITIAL

14. EYES
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Any indication that you are color blind
b. Glaucoma
c. Loss of vision in either eye
d. Cataracts
e. Detached retina, double vision and retinal hemorrhaging
f. Surgery to correct vision (RK, PRK, LASIK, etc.)
g. Other eye disorders

15. GENITOURINARY
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Frequent or painful urination
b Blood in urine
c. Sugar or protein in urine
d. Kidney disease
e. Prostate problems
f. Other genitourinary problems

16. NEUROLOGICAL AND MENTAL HEALTH
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Chronic headaches/migraines
b. Dizziness or fainting spells
c. A head injury, loss of memory, loss of consciousness or amnesia
d. Paralysis
e. Seizures, convulsions or epilepsy
f. Numbness or tingling
g. Meningitis, encephalitis, or other neurological problems
h. Depression
i. Bipolar Disorder
j. Anxiety Disorder
k. Post Traumatic Stress Disorder (PTSD)
l. Traumatic Brain Injury (TBI)
m. Alcohol/Drug dependency
n. Other mental health problems

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LAST NAME, FIRST NAME, MIDDLE INITIAL

17. CARDIOVASCULAR
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Pain or pressure in the chest
b. Swelling or pain in legs or feet
c. Irregular heart beats
d. Palpitation/skipped heartbeats
e. Heart murmur
f. High or low blood pressure
g. Heart attack
h. Stroke
i. Other cardiovascular problems

18. GASTROINTESTINAL
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Persistent nausea or vomiting
b. Chronic diarrhea or constipation
c. Colitis or diverticulitis
d. Crohn's disease or irritable bowel syndrome
e. Liver cirrhosis, infection or jaundice
f. Rectal bleeding or black tarry stools
g. Severe or frequent heartburn/stomach pain
h. Stomach, liver, intestinal trouble or ulcer
i. Hepatitis
j. Other gastrointestinal problems

19. SKIN
HAVE YOU EVER HAD:

If "yes," please indicate dates (mo/yr), treatment and explanation
Yes

No

a. Recurrent skin conditions that require medical attention
b. Skin allergies/rashes (e.g. eczema, psoriasis or contact dermatitis)
c. Moles that have changed in size or color
d. Skin cancer
e. Latex allergy
f. Other skin problems

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LAST NAME, FIRST NAME, MIDDLE INITIAL

If "yes," please indicate dates (mo/yr), treatment and explanation

20. EARS, NOSE AND THROAT
HAVE YOU EVER HAD:

Yes

No

a. Difficulty hearing
b. Ringing or buzzing in ears
c. Hearing aid
d. Chronic sinus trouble
e. Chronic nosebleeds
f. Chronic sneezing/running nose
g. Chronic sore throat
h. Difficulty swallowing
i. Ruptured ear drum
j. Other ear/nose/throat problems

21. OTHER SYMPTOMS AND DISEASES

If "yes," please indicate dates (mo/yr), treatment and explanation

HAVE YOU EVER HAD:

Yes

No

a. Unexplained weight loss or weight gain greater than 10 pounds
b. Hyperthyroidism
c. Hypothyroidism
d. Cancer
e. Chronic Anemia
f. Blood Disorder
g. Sleep Apnea
h. Hypoglycemia or hyperglycemia (including frequency)
i. Diabetes (complete additional questions shown below)
Type 1
Controlled by:

Type 2
Diet

Exercise

Medication

Medication: Name and Dosage
Side Effects Experienced (if any)

Most recent Hemoglobin A1C results

(must be performed within the past three months)

Date

HAVE YOU EVER HAD:
Yes
j. Any additional symptoms or diseases not yet mentioned

No
If "yes," please indicate dates (mo/yr), treatment and explanation

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LAST NAME, FIRST NAME, MIDDLE INITIAL

If "yes," please explain.

22. OCCUPATIONAL AND EXPOSURE HISTORY

Yes

No

Have you ever been off work more than a day because of a work-related
injury or illness?
Have you ever had to wear respiratory protection for a workplace
exposure (e.g. dust mask, half-face respirator)?

Have you ever received disability compensation?

Have you ever had a respiratory disease due to workplace exposures?

Have you ever developed a sensitivity due to workplace exposures
(e.g. contact dermatitis, eye or upper respiratory irritation)?

Have you ever changed jobs or duties due to health reasons?

Have you ever been rejected by or discharged
from the military for medical reasons?

Are you a Veteran receiving compensation based on one or more
medical conditions? (If yes, please list medical conditions for which you
are being compensated.)

Please list all employment during the past 10 years. Include a brief description of job duties and the work environment, including any specific hazards, starting
with your current position.
Dates of Employment

Agency/Company
(From)

-

Job Duties/Activities

Specific Hazards*

(To)

* Specific Hazards may include asbestos, chemicals, dust, fumes, gases, radiation, vibration, repetitive motion, intense light and loud noise. For any asbestos exposure,
please indicate the year and place of first exposure.
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LAST NAME, FIRST NAME, MIDDLE INITIAL

POSITION TITLE:

Public Health Veterinarian / Food Inspector / Consumer Safety Inspector

POSITION REQUIREMENTS:
Public Health Veterinarians (PHVs), Food Inspectors (FIs) and Consumer Safety Inspectors (CSIs) are involved in ante-mortem inspection of livestock or poultry
and post-mortem inspection of red meat or poultry. This inspection activity is performed in a noisy industrial environment with large moving machinery that cannot
be stopped instantly. Workstations and walkways can be extremely narrow and slippery. Excellent stability and balance is required. Frequent physical activities
such as walking, climbing, standing, and kneeling are required, including climbing and walking on catwalks.
Environmental Factors: *

Functional Requirements: *
Moderate light lifting 30 pounds, with occasional lifting of up to 50 lbs.

Working indoors and outdoors.

Repetitive motion of upper body and limbs (8 hours)

Excessive heat.

Reaching above shoulders.

Excessive cold.

Use of fingers-dexterity and normal sensation required.

Excessive humidity.

Both hands required.

Excessive dampness or chilling.

Walking (8 hours)

Excessive noise, continuous.

Standing (8 hours), in limited space (2 feet by 4 feet)

Slippery and uneven walking surfaces.

Climbing stairs and vertical ladders.

Working around machinery with moving parts.

Both legs required (prosthesis acceptable with full range of mobility)

Working around moving objects or vehicles.

Near vision using appropriate vision screening device.

Working with hands in water.

Far vision correctable to 20/40.

Working in close proximity to others.

Normal depth perception.

Protracted or irregular hours of work.

Normal peripheral vision (85 degrees temporarily in each eye)

Working with knives or other tools.

Normal Hearing

Exposure to offensive odors such as manure, blood, etc.

Ability to detect odors.

Possible exposure to noxious fumes.

Clear speech.

Will be required to wear appropriate safety protection.

Light lifting, 10 pounds.

Sub-freezing temperatures.

Ability to palpate organs & note product differences.

Summertime temperatures at 80 to 90 degrees.
Rapid, constant repetitive motion with hands/wrists.

Color vision allowing identification of subtle shades.

* Failure to fully meet a functional requirement is not automatically disqualifying. Please contact the hiring agency/employing agency directly if you wish to

request reasonable accommodation in connection with the functional requirements, environmental factors or other general position requirements. FSIS responds
to reasonable accommodation requests based on the facts of each case, conducting an individualized assessment to evaluate each request on its own merits.

Do you have any medical disorder or physical impairment that would interfere in any way with the full performance of the duties as described in the position
requirements, the functional requirements or the environmental factors?

Yes

No

(If yes, explain fully and discuss fully with the physician performing the examination.)

I certify the information I have given is true, complete and correct to the best of my knowledge and belief. These statements are made in good faith. I understand
that failure to self-report or knowingly provide a false answer to any question may be grounds for termination from the federal government. I also understand that
a knowing and willful false statement on this form may be punished by fine or imprisonment or both.
(Section 1001 of Title 18, United States Code)

Name of Applicant/Employee (Print your name)

Signature

Date

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LAST NAME, FIRST NAME, MIDDLE INITIAL

To the Physician/Examiner: The person you are about to examine will have to cope with the functional requirements, environmental factors and the general
position requirements listed on the previous page. Please take them into consideration as you perform your examination and report your findings and
conclusions. Please enter whether or not each system is within normal limits, and describe any abnormality (including diseases, scars, and disfigurements) if
present. Include a brief medical history on an item, if pertinent.
Please also note that applicants/employees may request reasonable accommodation for assistance in coping with the functional requirements,
environmental factors and other general position requirements listed on this form.

PART B. EXAMINER HISTORY AND GENERAL PHYSICAL EXAM
1. HEIGHT:

Feet

2. WEIGHT:

Pounds

Inches

3. EYES, EARS, NOSE AND THROAT. (Including sense of smell) Any abnormalities?

Is conversational hearing normal at 15 feet?
4. SPEECH. Any malfunction?

Yes

No

Yes

No

5. HEAD. (Including face, hair, and scalp) Any abnormalities?

Yes

6. SKIN and LYMPH NODES. (Including thyroid glands) Any abnormalities?

Does the applicant/employee have chronic dermatitis of the hands?
Is the individual allergic to latex?

7. ABDOMEN. Any abnormalities?

Yes

No

Yes

No

Yes

No

(If yes, please describe.)

(If yes, please describe.)

No

(If yes, please describe.)

Yes

Yes

No

(If yes, please describe.)

No

(If yes, please describe.)

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LAST NAME, FIRST NAME, MIDDLE INITIAL
8. PERIPHERAL BLOOD VESSELS. Any abnormalities?

Yes

No

9. EXTREMITIES. (Including range of motion, flexibility, and strength) Any abnormalities?

(If yes, please describe.)

Yes

No

(If yes, please describe.)

10. MOTION TESTS. Please administer the following two motion tests and indicate findings.
Tinel's Test

Positive

Negative

Phalen's Test

Positive

Negative

Carpal Tunnel Syndrome?

Yes

No

(If yes, please explain your findings.)

Lateral Epicondylitis?

Yes

No

(If yes, please explain your findings.)

Rotator Cuff Tear/Injury?

Yes

No

(If yes, please explain your findings.)

Are there any symptoms of:

11. URINALYSIS.

Normal

Abnormal (If abnormal, please explain your findings and any treatment prescribed.)

12. RESPIRATORY TRACT.
Any abnormal lung sounds?

Yes

No (If yes, please explain your findings.)

Are there any symptoms or history of Asthma?

Yes

No (If yes, please describer the asthma trigger, severity and treatment.)

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LAST NAME, FIRST NAME, MIDDLE INITIAL

13. BLOOD PRESSURE/PULSE.

BP Reading 1

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.

Date

Date

Pulse Reading

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 (3) 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.)

Include any known history of high blood pressure or other related conditions.

14. HEART. Size, Rate, Rhythm, Function, Abnormal Sounds.

15. BACK. Include any known history of back ailments, extent of condition and prognosis.

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 Tubercullin administered:
Date administered:

Date read:

Induration:

(measurement in mm)

Other results:
Is there any evidence of any other communicable or contagious disease?

Yes

No

(If yes, please explain your findings.)

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LAST NAME, FIRST NAME, MIDDLE INITIAL

17. NEUROLOGICAL AND MENTAL HEALTH. Is there any evidence of neurological or mental illness? (If yes, please explain your findings.)

18. MEDICAL HISTORY CONDITIONS. Any history of any other medical conditions that may affect the applicant's/employee's ability to perform the duties of the
position? (If yes, please explain your findings.)

19. CONCLUSIONS.
Please comment on the medical history provided by the applicant/employee in Part A, and summarize below any medical findings from your examination
which, in your opinion, would limit this person's performance of the job duties and/or would make the individual a hazard to themselves or others.
No Limiting Conditions for this Job

Limiting Conditions, as follows:

Physician's/Examiner's Name (type or print)
Physician's/Examiner's Signature

Date

Address
Telephone Number
Fax Number

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PART C. VISION
LAST NAME, FIRST NAME, MIDDLE INITIAL
20. COLOR VISION TESTS. The applicant/employee must be tested using one of the "ACCEPTABLE" color plate tests listed below.
(Please check the box by the test used.)
ISHIHARA (14 Plate Series)

H-R-R (HARDY RAUD-RITTLER)

FARNSWORTH D-15

DVORINE

TOKYO MEDICAL COLLEGE

AMERICAN OPTICAL (ACO)

ABILITY TO DISTINGUISH COLORS. Please enter applicant's capacity to distinguish primary colors and shades of color by checking full, partial or none.

CAPACITY
FULL

PARTIAL

NONE

PRIMARY COLORS
SHADES OF COLORS

→

PLEASE INDICATE THE NUMBER OF PLATES MISSED.

→

PLEASE INDICATE THE TOTAL NUMBER OF PLATES USED.

21. DISTANT VISION.
WHAT IS THE APPLICANT'S VISION WITHOUT GLASSES OR CONTACTS?
WHAT IS THE APPLICANT'S VISION WITH GLASSES OR CONTACTS?

LEFT 20/

RIGHT 20/

LEFT 20/

RIGHT 20/

22. NEAR VISION. [PLEASE NOTE: NEAR VISION MAY BE TESTED AT A DISTANCE OF 13 TO 16 INCHES WITH JAEGER TYPE 1 TO 4 LETTERS.]
WHAT IS THE APPLICANT'S VISION WITHOUT GLASSES OR CONTACTS?
WHAT IS THE APPLICANT'S VISION WITH GLASSES OR CONTACTS?

23. PERIPHERAL VISION.

Please measure peripheral visual fields.
Any abnormalities?

24. DEPTH PERCEPTION. Any abnormalities?

Yes

Yes

LEFT 20/

RIGHT 20/

LEFT 20/

RIGHT 20/

Degrees temporally:

Degrees nasally:

No (If yes, please explain.)

No

(If yes, please explain.)

Physician's/Examiner's Name (type or print)
Physician's/Examiner's Signature
Date
Address (include street, city, state and zip code)

Telephone Number

Fax Number

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PART D. BASELINE AUDIOGRAM TEST
LAST NAME, FIRST NAME, MIDDLE INITIAL

The Occupational Safety and Health (OSHA) requires the Baseline Audiogram Test sound pressure readings be in decibel indicators for 500, 1000, 2000,
3000, 4000, 6000 and 8000 Hertz. Important Note: If the test cannot be completed according to these guidelines, please refer the patient to a licensed or
certified audiologist, otolaryngologist, physician or technician whose equipment meets these requirements.
IF A HEARING AID IS USED, THE TEST MUST BE CONDUCTED WITH THE HEARING AID AND WITHOUT THE HEARING AID
25. HEARING TEST.

PLEASE NOTE: ALL READINGS MUST BE IN DECIBELS AND
MAKE SURE ALL HERTZ LEVELS ARE TESTED STARTING AT 0 DECIBELS.

WITHOUT
HEARING
AID

WITH
HEARING
AID

EAR

500

1000

2000

3000

4000

6000

8000

500

1000

2000

3000

4000

6000

8000

RIGHT
LEFT
EAR
RIGHT
LEFT

DATE OF HEARING TEST:
CALIBRATION DATE OF AUDIOMETER:
(MUST HAVE BEEN CALIBRATED WITHIN ONE YEAR OF THIS EXAMINATION)
ADDITIONAL SPACE FOR COMMENTS (Specify item):

I certify the audiogram test administered to the above named individual complies with OSHA standards.
Physicians/Examiner's Name
Physician's/Examiner's Signature:
Address (Street, City, State and Zip Code:

Telephone Number:
Fax Number:

PART E. AGENCY CERTIFICATION
THIS MEDICAL EXAMINATION FORM IS REVIEWED AND APPROVED.
FSIS OFFICIAL'S SIGNATURE:

TODAY'S DATE:

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