Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement

OMB 0704-0619

Latest Forms, Documents, and Supporting Material

Document Name
Form DD 3176 Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement Form and Instruction
0704-0619_SSA_4.25.22.docx Supporting Statement A
Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement Form and Instruction

All Historical Document Collections

202111-0704-010	Extension without change of a currently approved collection	2022-04-27
202110-0704-007 Approved without change	New collection (Request for a new OMB Control Number)	2021-10-19