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Request for Medical Exemption to the COIVD-19 Vaccination Requirement Form
Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form
OMB: 2105-0577
IC ID: 250528
OMB.report
DOT/OST
OMB 2105-0577
ICR 202111-2105-001
IC 250528
( )
Documents and Forms
Document Name
Document Type
Form 1320.13
Request for Medical Exemption to the COIVD-19 Vaccination Requirement Form
Form
1320.13 Request for Medical Exemption for the COIV-19 Vaccinatio
Request for Medical Exemption to COVID-19 Vaccination Form.pdf
Form
1320.13 Request for Medical Exemption for the COIV-19 Vaccinatio
Request for Medical Exemption to COVID-19 Vaccination Form.pdf
Form
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Request for Medical Exemption to the COIVD-19 Vaccination Requirement Form
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Mandatory
CFR Citation:
5 CFR 1320.13
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
1320.13
Request for Medical Exemption for the COIV-19 Vaccination Requirements Form
Request for Medical Exemption to COVID-19 Vaccination Form.pdf
Yes
Yes
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Transportation
Subfunction:
Ground Transportation
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
4,000
Number of Respondents for Small Entity:
0
Affected Public:
Federal Government
Percentage of Respondents Reporting Electronically:
99 %
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
4,000
0
4,000
0
0
0
Annual IC Time Burden (Hours)
8,000
0
8,000
0
0
0
Annual IC Cost Burden (Dollars)
2,320
0
2,320
0
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.