Information Collection

NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception

IC 249211 under ICR 202109-2700-001 · OMB 2700-0186.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
CertificationVaccinationText.docx nasa.aspcl5.medgate.com/gx2test/medicalpublicqrh/login.rails?qcode=ATTEST	Other-Attestation Form
Screen views of Attestation form.docx nasa.aspcl5.medgate.com/gx2test/medicalpublicqrh/login.rails?qcode=ATTEST	Other-Attestation Form
NF1699C Medical Exemption screenshots.docx nef.nasa.gov/forms/1602093956	Other-screenshots of form
NF-1699C REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT Request for Medical Exception.NF1699C.pdf nef.nasa.gov/forms/1602093956	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NF-1699C	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Request for Medical Exception.NF1699C.pdf	https://nef.nasa.gov/forms/1602093956	Yes	Yes	Fillable Fileable
Other-screenshots of form			NF1699C Medical Exemption screenshots.docx	https://nef.nasa.gov/forms/1602093956	Yes	Yes	Fillable Fileable

Line of Business: General Science and Innovation

Subfunction: Scientific and Technological Research and Innovation

Privacy Act System of Records

Title: NASA 10RAR Reasonable Accommodations Records

FR Citation: 86 FR 63073

Number of Respondents: 1,200

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,200	1,200
Annual IC Time Burden (Hours)	170	170
Annual IC Cost Burden (Dollars)	15,600	15,600

Documents for IC

table that charts IC Documents
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.