Information Collection

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

IC 250798 under ICR 202206-1405-004 · OMB 1405-0246.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction
DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT ds5158.far	Form and Instruction
DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT ds5158.far	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: Voluntary

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	DS-5158	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	ds5158.far		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	0	0
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.