Individuals or Households

Reasonable Accommodation Requests, FCC Forms 5626 and 5627

Documents and Forms

Document Name Document Type
Form FCC Form 5627 Individuals or Households Form
FCC Form 5627 Medical Consent Form Medical Consent 7.8_041023_updated 06222023.docx Form

Information Collection (IC) Details

IC Title:	Individuals or Households	Agency IC Tracking Number:	OWD

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1630

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	FCC Form 5627	Medical Consent Form	Medical Consent 7.8_041023_updated 06222023.docx		Yes	Yes	Fillable Fileable Signable

Line of Business: General Government

Subfunction: Central Fiscal Operations

Privacy Act System of Records
Title: EEOC/GOV-1, Equal Employment Opportunity (EEO) Complaint and Appeal Records	FR Citation: 81 FR 81116

Number of Respondents: 9	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	18	-36	54
Annual IC Time Burden (Hours)	49	-93	142
Annual IC Cost Burden (Dollars)	1,700	0	1,700

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.