Information Collection

COVID-19 Vaccine Supplemental Medical Provider Statement

IC 250233 under ICR 202111-0651-001 · OMB 0651-0087.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0651-0087 can be found here:

Documents and Forms

Document Name Document Type
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement Form
USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf Form
USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	COVID-19 Vaccine Supplemental Medical Provider Statement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation: 29 CFR 1614 20 CFR 1630 5 CFR 1320.13(c)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	USPTO-OEEOD 303	COVID-19 Vaccine Supplemental Medical Provider Statement	USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf		Yes	Yes	Fillable Fileable

Line of Business: General Government

Subfunction: Executive Functions

Privacy Act System of Records
Title: COMMERCE/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies, Except as Prohibited by Law	FR Citation: 72 FR 6200

Number of Respondents: 150	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	150	150
Annual IC Time Burden (Hours)	25	25
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.