Information Collection

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

IC 249810 under ICR 202111-0704-010 · OMB 0704-0619.

Documents and Forms

Document Name Document Type
Form DD 3176 Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement Form and Instruction
DD 3176 Request for a Medical Exemption or Delay to the COVID-19 dd3176 draft 20211123.PDF Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

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 20211123.PDF		Yes	Yes	Fillable Fileable Signable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Requested	Previously Approved
Annual Number of Responses for this IC	180,000	180,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	405,000	405,000

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.