Information Collection

Request for Medical Exemption to the COIVD-19 Vaccination Requirement Form

IC 250528 under ICR 202111-2105-001 · OMB 2105-0577.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1320.13 Request for Medical Exemption to the COIVD-19 Vaccination Requirement Form	Form
1320.13 Request for Medical Exemption for the COIV-19 Vaccinatio Request for Medical Exemption to COVID-19 Vaccination Form.pdf	Form
1320.13 Request for Medical Exemption for the COIV-19 Vaccinatio Request for Medical Exemption to COVID-19 Vaccination Form.pdf	Form

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 5 CFR 1320.13

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	1320.13	Request for Medical Exemption for the COIV-19 Vaccination Requirements Form	Request for Medical Exemption to COVID-19 Vaccination Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 4,000

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4,000	4,000
Annual IC Time Burden (Hours)	8,000	8,000
Annual IC Cost Burden (Dollars)	2,320	2,320

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.