Certificate of Medical Examination

OMB 0583-0167

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 and the leave bank program.

The latest form for Certificate of Medical Examination expires 2022-11-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 4339-1 Certificates of Medical Examination Form and Instruction
supporting statement A certificates of medical examination revision 2022.docx Supporting Statement A
Certificates of Medical Examination Form and Instruction

All Historical Document Collections

202206-0583-003 Approved with change	Revision of a currently approved collection	2022-09-27
202005-0583-002 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-05-20
202001-0583-003 Approved without change	No material or nonsubstantive change to a currently approved collection	2020-01-13
201910-0583-001 Approved with change	Revision of a currently approved collection	2019-10-18
201810-0583-003 Approved without change	Extension without change of a currently approved collection	2018-12-03
201508-0583-001 Approved with change	New collection (Request for a new OMB Control Number)	2015-09-25