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

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

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: Mandatory

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	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 %

	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

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.