Form DD 3176 DD 3176 Request for a Medical Exemption or Delay to the COVID-19

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

DD3176 DRAFT 20211019 (1)

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

OMB: 0704-0619

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0704-0619 can be found here:

2022-04-27 - Extension without change of a currently approved collection

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File Type	application/pdf
File Title	DD Form 3176, "REQUEST FOR A MEDICAL EXEMPTION OR DELAY TO THE COVID-19 VACCINATION REQUIREMENT"
Author	DoD Component
File Modified	2021-10-19
File Created	2021-10-18