Information Collection

Request For A Medical Exception To The Covid-19 Vaccination Requirement

IC 250798 under ICR 202206-1405-004 · OMB 1405-0246.

Documents and Forms

Document Name Document Type
Form DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction
DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT ds5158.far Form and Instruction
DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT ds5158.far Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	DS-5158	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	ds5158.far		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	20	20
Annual IC Time Burden (Hours)	0	0
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.