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

Documents and forms in this information collection
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

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	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 %

table that charts list of burden
	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

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.