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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 250346 under ICR 202111-3440-002 · OMB 3440-0002.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 1
Request for a Medical Exception to the COVID-19 Vaccination Requirement		 Form
1 Request for a Medical Exception to the COVID-19 Vaccinat
ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf 		Form
1 Request for a Medical Exception to the COVID-19 Vaccinat
ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf 		Form

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 1 Request for a Medical Exception to the COVID-19 Vaccination Requirement ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf Yes No Fillable Printable

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 100 0 100 0 0 0
Annual IC Time Burden (Hours) 125 0 125 0 0 0
Annual IC Cost Burden (Dollars) 5,176 0 5,176 0 0 0

Documents for IC
table that charts IC Documents
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.