Information Collection

Request For A Religious Accommodation To The Covid-19 Vaccination Requirement

IC 250799 under ICR 202206-1405-004 · OMB 1405-0246.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-5159 REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction
DS-5159 Request for a Religious Accomodation to the COVID-19 Vac Religious Accommodation Request Form.pdf	Form and Instruction
DS-5159 Request for a Religious Accomodation to the COVID-19 Vac Religious Accommodation Request Form.pdf	Form and Instruction

IC Title:

REQUEST FOR A RELIGIOUS ACCOMMODATION 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-5159	Request for a Religious Accomodation to the COVID-19 Vaccination Requirement	Religious Accommodation Request Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 80

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	80	80
Annual IC Time Burden (Hours)	1	1
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.