Information Collection

Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement

IC 251045 under ICR 202201-3124-001 · OMB 3124-0016.

Documents and Forms

Document Name Document Type
Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement Form and Instruction
Request for a Medical Exception to the COVID-19 Vaccinat Request for a Medical Exception to the COVID-19 Vaccination Requirement (Final).pdf Form and Instruction
Request for a Medical Exception to the COVID-19 Vaccinat Request for a Medical Exception to the COVID-19 Vaccination Requirement (Final).pdf Form and Instruction
Request for a Religious Exception to the COVID-19 Vaccin Request for a Religious Exception to the COVID-19 Vaccination Requirement.pdf Form and Instruction
Request for a Religious Exception to the COVID-19 Vaccin Request for a Religious Exception to the COVID-19 Vaccination Requirement.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	n/a	Request for a Medical Exception to the COVID-19 Vaccination Requirement	Request for a Medical Exception to the COVID-19 Vaccination Requirement (Final).pdf		Yes	Yes	Fillable Fileable Signable
Form and Instruction	n/a	Request for a Religious Exception to the COVID-19 Vaccination Requirement	Request for a Religious Exception to the COVID-19 Vaccination Requirement.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title: MSPB-3, Reasonable Accommodations	FR Citation: 86 FR 73001

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	70	70
Annual IC Time Burden (Hours)	70	70
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.