Information Collection

Medical Certification for COVID-19 Vaccine Exception

IC 250134 under ICR 202111-3084-001 · OMB 3084-0170.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3084-0170 can be found here:

Documents and Forms

Document Name Document Type
Form Unknown Medical Certification for COVID-19 Vaccine Exception Form and Instruction
Unknown Request for a Medical Exception to the COVID-19 Vaccinat DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf Form and Instruction
Unknown Request for a Medical Exception to the COVID-19 Vaccinat DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf Form and Instruction
Not Applicable Privacy Act Statement for Medical Exception Form to COVI Privacy Act Statement for Medical Exception Form Screenshots_Redacted.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Certification for COVID-19 Vaccine Exception	Agency IC Tracking Number:

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	Unknown	Request for a Medical Exception to the COVID-19 Vaccination Requirement	DISABILITY REQUEST FORM - 20211004_510pm - MH508.pdf		Yes	Yes	Fillable Fileable Signable
Form	Not Applicable	Privacy Act Statement for Medical Exception Form to COVID-19 Vaccination Requirement	Privacy Act Statement for Medical Exception Form Screenshots_Redacted.pdf		Yes	Yes	Fillable Fileable Signable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title: General Personnel Records (FTC-II-1) and when applicable, Employee Health Care Records (FTC-II-10) and Employee Medical File System of Records (OPM/GOVT-10)	FR Citation: 84 FR 16493

Number of Respondents: 35	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	35	35
Annual IC Time Burden (Hours)	6	6
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.