Information Collection

FMSHRC Medical Exception Request Form

IC 250495 under ICR 202201-3079-001 · OMB 3079-0001.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FMSHRC-09-001 FMSHRC Medical Exception Request Form	Form and Instruction
FMSHRC-09-001 FMSHRC Medical Exception Request Form FMSHRC Medical Exception Request Form_V3_11-22-2021.pdf	Form and Instruction
FMSHRC-09-001 FMSHRC Medical Exception Request Form FMSHRC Medical Exception Request Form_V3_11-22-2021.pdf	Form and Instruction
FMSHRC-09-002 Medical Exception Request to the Vaccination Requirement 2022-2-22 FMSHRC Medical Exception Request Form.pdf	Form and Instruction
FMSHRC-09-002 Medical Exception Request to the Vaccination Requirement 2022-2-22 FMSHRC Medical Exception Request Form.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	FMSHRC-09-001	FMSHRC Medical Exception Request Form	FMSHRC Medical Exception Request Form_V3_11-22-2021.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	FMSHRC-09-002	Medical Exception Request to the Vaccination Requirement	2022-2-22 FMSHRC Medical Exception Request Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Central Personnel

Privacy Act System of Records

Title: Workplace Requests and Reasonable Accommodation Records, FMSHRC-09

FR Citation: 86 FR 66301

Number of Respondents: 6

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	6	6
Annual IC Time Burden (Hours)	24	24
Annual IC Cost Burden (Dollars)	600	600

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.