Information Collection

Business or other for-profit

IC 249996 under ICR 202111-3060-001 · OMB 3060-1295.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 5643 Business or other for-profit	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

IC Title:

Business or other for-profit

Agency IC Tracking Number:

OWD

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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	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: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	33	33
Annual IC Time Burden (Hours)	17	17
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.