Information Collection

Request for a Religious Exception to the COVID-19 Vaccine Requirement

IC 249970 under ICR 202110-1557-004 · OMB 1557-0353.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1557-0353 can be found here:

Documents and Forms

Document Name Document Type
Request for a Religious Exception to the COVID-19 Vaccine Requirement Form
Religious Accommodation Request Form religious-accommodation-request-form (1).pdf Form
Religious Accommodation Form religious-accommodation-request-form (1).docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for a Religious Exception to the COVID-19 Vaccine Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Religious Accommodation Form	religious-accommodation-request-form (1).docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Financial Sector Oversight

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 4	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4
Annual IC Time Burden (Hours)	2	2
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.