Information Collection

Request for Medical Exception to COVID-19 Vaccination Requirement

IC 250509 under ICR 202111-1212-001 · OMB 1212-0075.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1212-0075 can be found here:

Documents and Forms

Document Name Document Type
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement Form and Instruction
Part I Request for Medical Exception to COVID-19 Vaccination Re Medical Exception Request Part I - COVID-19 Vaccination Requirement.pdf Form and Instruction
Part II Request for Medical Exception to COVID-19 Vaccination Re MedicalExceptionRequestPartII-COVID-19VaccinationRequirement (2).pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Medical Exception to COVID-19 Vaccination Requirement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Part I	Request for Medical Exception to COVID-19 Vaccination Requirement, Part I	Medical Exception Request Part I - COVID-19 Vaccination Requirement.pdf		Yes	Yes	Fillable Printable
Form and Instruction	Part II	Request for Medical Exception to COVID-19 Vaccination Requirement	MedicalExceptionRequestPartII-COVID-19VaccinationRequirement (2).pdf		Yes	Yes	Fillable Printable

Line of Business: Income Security

Subfunction: General Retirement and Disability

Privacy Act System of Records
Title: PBGC-21: Reasonable Accommodation Records	FR Citation: 29 FR 1630

Number of Respondents: 5	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5	5
Annual IC Time Burden (Hours)	3	3
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.