Information Collection

Eib 21-03 Request For A Medical Exception To The Covid-19 Vaccination Requirement

IC 250594 under ICR 202111-3048-010 · OMB 3048-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3048-0058 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form EIB 21-03 EIB 21-03 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction
EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf	Form and Instruction
EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf	Form and Instruction

IC Title:

EIB 21-03 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT

Agency IC Tracking Number:

EIB 21-03

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 and Instruction	EIB 21-03	Request for a Medical Exception to COVID-19 Vaccination	EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf	https://www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title: EXIM â 21-03: Reasonable Accommodation Records

FR Citation: 86 FR 63377

Number of Respondents: 12

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	24	24
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.