Individuals or Households

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3060-1295 can be found here:

Documents and Forms

Document Name Document Type
Form FCC Form 5643 Individuals or Households Form and Instruction
FCC Form 5643 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT FCC Form 5643 DISABILITY REQUEST FORM - Vaccination FCC 10-29-21 v2 FINAL VERSION.pdf Form and Instruction
FCC Form 5643 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT FCC Form 5643 DISABILITY REQUEST FORM - Vaccination FCC 10-29-21 v2 FINAL VERSION.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Individuals or Households	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	FCC Form 5643 DISABILITY REQUEST FORM - Vaccination FCC 10-29-21 v2 FINAL VERSION.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: FCC/OWD-1, Reasonable Accommodation Requests	FR Citation: 84 FR 3163

Number of Respondents: 33	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	33	33
Annual IC Time Burden (Hours)	16	16
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.