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

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

OMB: 0704-0619

IC ID: 249810

Information Collection (IC) Details

View Information Collection (IC)

Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction DD 3176 Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement DD3176 DRAFT 20211019 (1).pdf Yes Yes Fillable Fileable Signable

Defense and National Security Operational Defense

 

180,000 0
   
Individuals or Households
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 180,000 0 180,000 0 0 0
Annual IC Time Burden (Hours) 15,000 0 15,000 0 0 0
Annual IC Cost Burden (Dollars) 405,000 0 405,000 0 0 0

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