Information Collection

DOC Request for Medical Exemption Form

IC 249905 under ICR 202110-0690-001 · OMB 0690-0036.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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		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 %

table that charts list of burden
	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

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.