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

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

OMB: 1225-0092

IC ID: 250283

Information Collection (IC) Details

View Information Collection (IC)

Request for a Medical Exception to the COVID-19 Vaccination Requirement
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction DL1-7071 Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement Form.pdf Yes Yes Fillable Fileable

Health Immunization Management

DOL/CENTRAL-6  81 FR 25766

250 0
   
Individuals or Households
 
   95 %

  Approved 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 250 250 0 0 0 0
Annual IC Time Burden (Hours) 42 42 0 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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