OMB
.report
Search
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
OMB.report
DOD/DODDEP
OMB 0704-0619
ICR 202111-0704-010
IC 249810
( )
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
Federal Enterprise Architecture Business Reference Module
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
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
0
0
0
180,000
Annual IC Time Burden (Hours)
15,000
0
0
0
0
15,000
Annual IC Cost Burden (Dollars)
405,000
0
0
0
0
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.