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

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

Information Collection (IC) Details

View Information Collection (IC)

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

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 %

	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

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.