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Request for a Medical Exception to the COVID-19 Vaccination Requirement
Request for a Medical Exception to the COVID-19 Vaccination Requirement
OMB: 3440-0002
IC ID: 250346
OMB.report
ODNI
OMB 3440-0002
ICR 202111-3440-002
IC 250346
( )
Documents and Forms
Document Name
Document Type
Form 1
Request for a Medical Exception to the COVID-19 Vaccination Requirement
Form
1 Request for a Medical Exception to the COVID-19 Vaccinat
ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf
Form
1 Request for a Medical Exception to the COVID-19 Vaccinat
ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf
Form
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:
New
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
1
Request for a Medical Exception to the COVID-19 Vaccination Requirement
ATTACH 1 (ODNI Form COVID-19 Med. Exemp. Request)_U.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Defense and National Security
Subfunction:
Strategic National and Theater Defense
Privacy Act System of Records
Title:
ODNI-10, "Office of Intelligence Community Equal Employment Opportunity and Diversity Office (IC EEOD) Records, 80 FR 30276 (May 27, 2015)-also available at [https:/lwww.govinfo.gov/content/pkg/FR-201
FR Citation:
15 FR 527
Number of Respondents:
100
Number of Respondents for Small Entity:
0
Affected Public:
Federal Government
Percentage of Respondents Reporting Electronically:
0 %
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
100
0
100
0
0
0
Annual IC Time Burden (Hours)
125
0
125
0
0
0
Annual IC Cost Burden (Dollars)
5,176
0
5,176
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.