Information Collection

Medical Certification for COVID-19 Vaccine Exception for Prospective Employees with Job Offer

IC 250593 under ICR 202111-3084-003 · OMB 3084-0170.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Medical Exception Request-Letter-11_29_2021.pdf	Other-Emergency Justification Letter
Medical Exception Request-Letter-11_29_2021.pdf	Other-Emergency Justification Letter

IC Title:

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
Other-Emergency Justification Letter			Medical Exception Request-Letter-11_29_2021.pdf		Yes	Yes	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title: FTC-II-4

FR Citation: 84 FR 16493

Number of Respondents: 2

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4	0
Annual IC Time Burden (Hours)	1	0	1
Annual IC Cost Burden (Dollars)	0	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.