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Federal forms, ICRs, and supporting documents

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FMSHRC Medical Exception Request Form

IC 250495 under ICR 202201-3079-001 · OMB 3079-0001.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

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FMSHRC Medical Exception Request Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction FMSHRC-09-001 FMSHRC Medical Exception Request Form FMSHRC Medical Exception Request Form_V3_11-22-2021.pdf Yes Yes Fillable Fileable
Form and Instruction FMSHRC-09-002 Medical Exception Request to the Vaccination Requirement 2022-2-22 FMSHRC Medical Exception Request Form.pdf Yes Yes Fillable Fileable

General Government Central Personnel

Workplace Requests and Reasonable Accommodation Records, FMSHRC-09  86 FR 66301

6 0
   
Federal Government
 
   100 %

  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 6 0 0 0 0 6
Annual IC Time Burden (Hours) 24 0 0 0 0 24
Annual IC Cost Burden (Dollars) 600 0 0 0 0 600

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