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

Documents and forms in this information collection
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

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
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 %

table that charts list of burden
	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

table that charts IC Documents
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.