OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Request for Medical Exception to COVID-19 Vaccination Requirement

IC 250509 under ICR 202204-1212-001 · OMB 1212-0075.

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

View Information Collection (IC)

Request for Medical Exception to COVID-19 Vaccination Requirement
 
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 Part I Request for Medical Exception to COVID-19 Vaccination Requirement, Part I Medical Exception Request Part I - COVID-19 Vaccination Requirement.pdf Yes Yes Fillable Printable
Form and Instruction Part II Request for Medical Exception to COVID-19 Vaccination Requirement MedicalExceptionRequestPartII-COVID-19VaccinationRequirement (2).pdf Yes Yes Fillable Printable

Income Security General Retirement and Disability

PBGC-21: Reasonable Accommodation Records  29 FR 1630

2 0
   
Private Sector Businesses or other for-profits
 
   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 2 0 -3 0 0 5
Annual IC Time Burden (Hours) 1 0 -2 0 0 3
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.