Individuals or Households

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

OMB: 3060-1295

IC ID: 249992

Information Collection (IC) Details

View Information Collection (IC)

Individuals or Households OWD
 
No New
 
Mandatory
 

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

General Government Central Fiscal Operations

FCC/OWD-1, Reasonable Accommodation Requests  84 FR 3163

33 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 33 0 33 0 0 0
Annual IC Time Burden (Hours) 16 0 16 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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