Information Collection

Request for a Religious Exception to the Covid-19 Vaccination Requirement

IC 253751 under ICR 202205-1225-003 · OMB 1225-0092.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DL1-7071A Request for a Religious Exception to the Covid-19 Vaccination Requirement	Form and Instruction
DL1-7071A Request for a Religious Exception to the Covid-19 Vaccin DL1-7071B.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	DL1-7071A	Request for a Religious Exception to the Covid-19 Vaccination Requirement	DL1-7071B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title: DOL/OASAM-38

FR Citation: 87 FR 16766

Number of Respondents: 10

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
Annual Number of Responses for this IC	10	10
Annual IC Time Burden (Hours)	3	3
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.