FMSHRC Medical Exception Request Form

Medical Exception Request to the COVID-19 Vaccination Requirement

Documents and Forms

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

Information Collection (IC) Details

IC Title:	FMSHRC Medical Exception Request Form	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:

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 %

	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

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.