Information Collection

Certificates of Medical Examination

IC 218023 under ICR 202206-0583-003 · OMB 0583-0167.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0583-0167 can be found here:

Documents and Forms

Document Name Document Type
Form 4339-1 Certificates of Medical Examination Form and Instruction
4339-1 Certificate of Medical Examination (with Report of Medic FSIS 4339-1 Certificate of Medical Examination (with Report of Medical History) 05202020.pdf Form and Instruction
4339-1 Certificate of Medical Examination (with Report of Medic FSIS 4339-1 Certificate of Medical Examination (with Report of Medical History) 05202020.pdf Form and Instruction
4306-5 Medical Documentation for Employees Reasonable Accommoda FSIS 4306-5 MEDICAL DOCUMENTATION FOR EMPLOYEES REASONABLE ACCOMMODATION REQUEST _v8RE508_BAK.pdf Form and Instruction
4306-5 Medical Documentation for Employees Reasonable Accommoda FSIS 4306-5 MEDICAL DOCUMENTATION FOR EMPLOYEES REASONABLE ACCOMMODATION REQUEST _v8RE508_BAK.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Certificates of Medical Examination	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 5 CFR 339

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	4339-1	Certificate of Medical Examination (with Report of Medical History)	FSIS 4339-1 Certificate of Medical Examination (with Report of Medical History) 05202020.pdf		Yes	No	Fillable Printable
Form and Instruction	4306-5	Medical Documentation for Employees Reasonable Accommodation Request	FSIS 4306-5 MEDICAL DOCUMENTATION FOR EMPLOYEES REASONABLE ACCOMMODATION REQUEST _v8RE508_BAK.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: Employee Medical File System (OPM/Govt-10)	FR Citation: 75 FR 35099

Number of Respondents: 1,250	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	1,250	450	800
Annual IC Time Burden (Hours)	1,542	733	809
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.