Information Collection

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

IC 250511 under ICR 202111-0503-001 · OMB 0503-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0503-0027 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT DISABILITY REQUEST FORM.pdf	Form and Instruction

IC Title:

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

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614 29 CFR 1630

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	N/A	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	DISABILITY REQUEST FORM.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: USDA Personnel Public Health Emergency Records System, USDA/O)SEC01

FR Citation: 86 FR 61747

Number of Respondents: 2,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
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.