Information Collection

Medical Certification for COVID-19 Vaccine Exception for Prospective Employees with Job Offer

IC 250593 under ICR 202111-3084-003 · OMB 3084-0170.

Documents and Forms

Document Name Document Type
Medical Exception Request-Letter-11_29_2021.pdf Other-Emergency Justification Letter
Medical Exception Request-Letter-11_29_2021.pdf Other-Emergency Justification Letter

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Certification for COVID-19 Vaccine Exception for Prospective Employees with Job Offer	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
Other-Emergency Justification Letter			Medical Exception Request-Letter-11_29_2021.pdf		Yes	Yes	Fillable Printable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records
Title: FTC-II-4	FR Citation: 84 FR 16493

Number of Respondents: 2	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: 0 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	4	4	0
Annual IC Time Burden (Hours)	1	0	1
Annual IC Cost Burden (Dollars)	0	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.