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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.