Dd form 3176-2026

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The document is a request form for federal employees seeking a medical exemption or delay from the COVID-19 vaccination requirement. It outlines the necessary information to be provided by both the employee and their healthcare provider, including details about the medical condition justifying the exemption. The form also includes privacy statements, instructions for completion, and legal implications of misrepresentation.

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Click ‘Get Form’ to open the dd form 3176 in the editor.
Begin with Part 1, where you will enter your personal information. Fill in your name, DoD ID number, office symbol, date of request, position/title, supervisor's name, and phone number.
In blocks 8-10, provide detailed descriptions of your medical condition and explain why it prevents vaccination. Use the narrative space effectively to ensure clarity.
If additional space is needed for your responses, utilize the continuation block (Block 11) by annotating the section and line number.
Complete Part 2 by having a licensed health care provider fill out their section. Ensure they provide necessary medical certifications and sign the form.
Review all entries for accuracy before submitting. Signing this form confirms that all information is true to the best of your knowledge.

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