Information Collection

Request For A Medical Exception To The Covid-19 Vaccination Requirement

IC 250289 under ICR 202205-1902-003 · OMB 1902-0320.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1902-0320 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1000 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction
1000 Request for a Medical Exception to the COVID-19 Vaccinat FERC Form No. 1000.docx	Form and Instruction

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:

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	1000	Request for a Medical Exception to the COVID-19 Vaccination Requirement	FERC Form No. 1000.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: Workforce Management

Subfunction: Worker Safety

Privacy Act System of Records

Title: FERC SORN-24

FR Citation: 86 FR 64923

Number of Respondents: 24

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	24	24
Annual IC Time Burden (Hours)	12	12
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.