DOC Request for Medical Exemption Form

Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0690-0036 can be found here:

Documents and Forms

Document Name Document Type
DOC Request for Medical Exemption Form Form and Instruction
DOC Request for a Medical Exemption Form DOC Medical Exception Request Form 102621.pdf Form and Instruction
DOC Request for a Medical Exemption Form DOC Medical Exception Request Form 102621.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	DOC Request for Medical Exemption Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction		DOC Request for a Medical Exemption Form	DOC Medical Exception Request Form 102621.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,000	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	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.