Information Collection

Request For A Religious Accommodation To The Covid-19 Vaccination Requirement

IC 250799 under ICR 202112-1405-009 · OMB 1405-0246.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0246 can be found here:

Documents and Forms

Document Name Document Type
REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction
Religious Accomodation Request Form Religious Accommodation Request Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT	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	NA	Religious Accomodation Request Form	Religious Accommodation Request Form.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	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	80	80
Annual IC Time Burden (Hours)	1	1
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.