Information Collection

Federal Government

IC 249997 under ICR 202112-3060-003 · OMB 3060-1295.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FCC Form 5643 Federal Government	Form and Instruction
FCC Form 5643 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT MEDICAL EXCEPTION FORM - Vaccination FCC 12 7 21 v7 FINAL.pdf	Form and Instruction
FCC Form 5643 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT MEDICAL EXCEPTION FORM - Vaccination FCC 12 7 21 v7 FINAL.pdf	Form and Instruction

IC Title:

Federal Government

Agency IC Tracking Number:

OWD

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

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	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	MEDICAL EXCEPTION FORM - Vaccination FCC 12 7 21 v7 FINAL.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records

Title: FCC/OWD-1, Reasonable Accommodation Requests

FR Citation: 84 FR 3163

Number of Respondents: 34

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	34	34
Annual IC Time Burden (Hours)	17	17
Annual IC Cost Burden (Dollars)	0	0

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.