Information Collection

Request for a Medical Exception to the COVID-19 Vaccination Requirement

IC 250283 under ICR 202205-1225-003 · OMB 1225-0092.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DL1-7071 Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction
DL1-7071 Request for a Medical Exception or Delay to the COVID-19 Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement 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	DL1-7071	Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement	Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement Form.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: DOL/CENTRAL-6

FR Citation: 81 FR 25766

Number of Respondents: 260

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	260	10	250
Annual IC Time Burden (Hours)	45	3	42
Annual IC Cost Burden (Dollars)	0	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.