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

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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Request for a Medical Exception to the COVID-19 Vaccination Requirement	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	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 %

	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

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.