Information Collection

EPA Medical Certification for Covid-19 Vaccination Exception Request.

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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EPA Medical Certification for Covid-19 Vaccination Exception Request.	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	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 %

	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

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.