4306-5 Medical Documentation for Employees Reasonable Accommoda

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 10 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

MEDICAL DOCUMENTATION FOR EMPLOYEE’S REASONABLE ACCOMMODATION REQUEST
(To be completed by Health Care Provider)

INSTRUCTIONS: Your patient is an employee or an applicant for employment with the U.S. Department of Agriculture
(USDA), Food Safety and Inspection Service (FSIS) and has requested a reasonable accommodation under the
Rehabilitation Act of 1973 as amended due to functional limitations caused by a disability.
Please provide the following information to your patient so he/she may send it to:
[email protected].

1. Patient Name:

2. Describe the nature, severity, and likely duration of
the impairment:

3. Describe the major life activities the impairment limits
(i.e. walking, lifting, breathing, hearing, etc.):

4. Describe the extent or degree to which the
impairment limits the major life activities:

5. Describe the functional reason the individual requires
accommodation and the accommodation requested:

6. Describe how the accommodation will assist the individual in applying for a job, performing the essential
functions of his/her position, or enjoying the benefits of employment (as appropriate):

Name of Health Care Provider:

Phone Number:

Health Care Provider Signature:
FSIS Form 4306-5 (01/29/2019)

Health Care Provider Facility Address:

Email Address:

Fax Number:

Date:

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.

FSIS Form 4306-5 (01/29/2019)