Information Collection

EPA Medical Certification for Covid-19 Vaccination Exception Request.

IC 250500 under ICR 202111-2030-002 · OMB 2030-0053.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TBD EPA Medical Certification for Covid-19 Vaccination Exception Request.	Form
TBD EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEP EPA Medical Certification for Covid-19 Vaccine Exception Request.docx	Form
TBD EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEP 12-2-2021 - EPA Medical Certification for Covid-19 Vaccine Exception Request Form.docx	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	TBD	EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEPTION REQUEST	12-2-2021 - EPA Medical Certification for Covid-19 Vaccine Exception Request Form.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 175

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	175	175
Annual IC Time Burden (Hours)	175	175
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.