Information Collection

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

IC 250005 under ICR 202111-3147-001 · OMB 3147-0028.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3147-0028 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction
Request for a Medical Exception to the COVID-19 Vaccinat NTSB FORM Request for Medical Exception.pdf	Form and Instruction
Request for a Medical Exception to the COVID-19 Vaccinat NTSB FORM Request for Medical Exception.pdf	Form and Instruction

IC Title:

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: Required to Obtain or Retain Benefits

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	N/A	Request for a Medical Exception to the COVID-19 Vaccination Requirement	NTSB FORM Request for Medical Exception.pdf		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Air Transportation

Privacy Act System of Records

Title: NTSB 28 Employee Medical Folders

FR Citation: 77 FR 62060

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 85 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	20	20
Annual IC Cost Burden (Dollars)	1,012	1,012

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.