Information Collection

COVID-19 Vaccine Supplemental Medical Provider Statement

IC 250233 under ICR 202111-0651-001 · OMB 0651-0087.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0651-0087 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement	Form
USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf	Form
USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf	Form

IC Title:

COVID-19 Vaccine Supplemental Medical Provider Statement

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614 20 CFR 1630 5 CFR 1320.13(c)

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	USPTO-OEEOD 303	COVID-19 Vaccine Supplemental Medical Provider Statement	USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: COMMERCE/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies, Except as Prohibited by Law

FR Citation: 72 FR 6200

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
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.