Information Collection

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

IC 250869 under ICR 202112-3202-001 · OMB 3202-0005.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction
1 Request for a Medical Exception to the COVID-19 Vaccinat OSHRC--Medical Exception Request Form^11 17 2021.pdf	Form and Instruction
1 Request for a Medical Exception to the COVID-19 Vaccinat OSHRC--Medical Exception Request Form^11 17 2021.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	1	Request for a Medical Exception to the COVID-19 Vaccination Requirement	OSHRC--Medical Exception Request Form^11 17 2021.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records

Title: Reasonable Accommodation Records

FR Citation: 86 FR 64532

Number of Respondents: 3

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3	3
Annual IC Time Burden (Hours)	9	9
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.