Information Collection

Eib 21-03 Request For A Medical Exception To The Covid-19 Vaccination Requirement

IC 250594 under ICR 202111-3048-010 · OMB 3048-0058.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3048-0058 can be found here:

Documents and Forms

Document Name Document Type
Form EIB 21-03 EIB 21-03 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction
EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf Form and Instruction
EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	EIB 21-03 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Agency IC Tracking Number:	EIB 21-03

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	EIB 21-03	Request for a Medical Exception to COVID-19 Vaccination	EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination Form_v3 - fillable.pdf	https://www.exim.gov/sites/default/files/pub/pending/eib21-03.pdf	Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title: EXIM â 21-03: Reasonable Accommodation Records	FR Citation: 86 FR 63377

Number of Respondents: 12	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	12	12
Annual IC Time Burden (Hours)	24	24
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.