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

Document Name Document 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)

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: Voluntary

CFR Citation:

Information Collection 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

Line of Business: Defense and National Security

Subfunction: Strategic National and Theater Defense

Privacy Act System of Records
Title: ODNI-10, "Office of Intelligence Community Equal Employment Opportunity and Diversity Office (IC EEOD) Records, 80 FR 30276 (May 27, 2015)-also available at [https:/lwww.govinfo.gov/content/pkg/FR-201	FR Citation: 15 FR 527

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	125	125
Annual IC Cost Burden (Dollars)	5,176	5,176

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.