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COVID-19 Vaccine Supplemental Medical Provider Statement

IC 250233 under ICR 202201-0651-001 · OMB 0651-0087.

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COVID-19 Vaccine Supplemental Medical Provider Statement
 
No Modified
 
Voluntary
 
29 CFR 1614 20 CFR 1630 5 CFR 1320.13(c)

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement USPTO OEEOD 303 COVID-19 Supplemental Medical Provider Form 20211109.pdf Yes Yes Fillable Fileable

General Government Executive Functions

COMMERCE/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies, Except as Prohibited by Law  72 FR 6200

150 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   75 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 150 0 0 0 0 150
Annual IC Time Burden (Hours) 25 0 0 0 0 25
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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