Information Collection

Request for a Medical Exemption to the COVID -19 Vaccination Requirement

IC 250511 under ICR 202111-0503-001 · OMB 0503-0027.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0503-0027 can be found here:

Documents and Forms

Document Name Document Type
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT DISABILITY REQUEST FORM.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for a Medical Exemption to the COVID -19 Vaccination Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614 29 CFR 1630

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	N/A	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	DISABILITY REQUEST FORM.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title: USDA Personnel Public Health Emergency Records System, USDA/O)SEC01	FR Citation: 86 FR 61747

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	333	333
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.