Information Collection

Request for Medical Exception to COVID-19 Vaccination Requirement

IC 250509 under ICR 202111-1212-001 · OMB 1212-0075.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0075 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction
Part I Request for Medical Exception to COVID-19 Vaccination Re Medical Exception Request Part I - COVID-19 Vaccination Requirement.pdf	Form and Instruction
Part II Request for Medical Exception to COVID-19 Vaccination Re MedicalExceptionRequestPartII-COVID-19VaccinationRequirement (2).pdf	Form and Instruction

IC Title:

Request for Medical Exception to COVID-19 Vaccination 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:

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	Part I	Request for Medical Exception to COVID-19 Vaccination Requirement, Part I	Medical Exception Request Part I - COVID-19 Vaccination Requirement.pdf		Yes	Yes	Fillable Printable
Form and Instruction	Part II	Request for Medical Exception to COVID-19 Vaccination Requirement	MedicalExceptionRequestPartII-COVID-19VaccinationRequirement (2).pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records

Title: PBGC-21: Reasonable Accommodation Records

FR Citation: 29 FR 1630

Number of Respondents: 5

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	3	3
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.