Information Collection

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

IC 250291 under ICR 202111-3145-003 · OMB 3145-0262.

Documents and Forms

Document Name Document Type
Form NSF NSF Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction
NSF NSF Medical Reasonable Accommodation Request NSF DISABILITY REQUEST FORM - DRAFT V.5 - 2021-11-09.pdf Form and Instruction
NSF NSF Medical Reasonable Accommodation Request NSF DISABILITY REQUEST FORM - DRAFT V.7 - 2021-11-16.pdf Form and Instruction
Medical Accommodation Privacy Act statement.pdf Privacy Act Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	NSF Request for a Medical Exception to the COVID-19 Vaccination Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	NSF	NSF Medical Reasonable Accommodation Request	NSF DISABILITY REQUEST FORM - DRAFT V.7 - 2021-11-16.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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	100	100
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	23,536	23,536

Documents for IC

Title	Document	Date Uploaded
Privacy Act Statement	Medical Accommodation Privacy Act statement.pdf	11/12/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.