Information Collection

Medical Certification for COVID-19 Vaccine Exception

IC 250134 under ICR 202111-3084-001 · OMB 3084-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3084-0170 can be found here:

2021-11-30 - Revision of a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Unknown Medical Certification for COVID-19 Vaccine Exception	Form and Instruction
Unknown Request for a Medical Exception to the COVID-19 Vaccinat DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf	Form and Instruction
Unknown Request for a Medical Exception to the COVID-19 Vaccinat DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf	Form and Instruction
Not Applicable Privacy Act Statement for Medical Exception Form to COVI Privacy Act Statement for Medical Exception Form Screenshots_Redacted.pdf	Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Medical Certification for COVID-19 Vaccine Exception

Agency IC Tracking Number:

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	Unknown	Request for a Medical Exception to the COVID-19 Vaccination Requirement	DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf		Yes	Yes	Fillable Fileable Signable
Form	Not Applicable	Privacy Act Statement for Medical Exception Form to COVID-19 Vaccination Requirement	Privacy Act Statement for Medical Exception Form Screenshots_Redacted.pdf		Yes	Yes	Fillable Fileable Signable

Federal Enterprise Architecture Business Reference Module

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title: General Personnel Records (FTC-II-1) and when applicable, Employee Health Care Records (FTC-II-10) and Employee Medical File System of Records (OPM/GOVT-10)

FR Citation: 84 FR 16493

Number of Respondents: 35

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	6	6
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.