NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form NF-1699C REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction	New	Available
NASA 10HIMS SORN.pdf	Supplementary Document	Uploaded 2021-09-08	Repair queued
PRA Emergency Clearance Letter SIGNED.pdf	Supplementary Document	Uploaded 2021-09-08	Repair queued
Supporting Statement Vaccination Attestation.docx	Supporting Statement A	Uploaded 2021-09-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249211	NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception	Form and Instruction	New	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
249211	NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception	Other-screenshots of form	New

ICR Details

OMB Control No: 2700-0186	ICR Reference No: 202109-2700-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: NASA	Agency Tracking No:
Title: NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 09/10/2021
OIRA Conclusion Action: Approved with change	Conclusion Date: 11/19/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/08/2021
Terms of Clearance: This collection is approved for 6 months only based on the revised materials provided by the Agency. Should the agency want to use this collection for more than 6 months, the agency should publish a 60 and 30 day notice.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	6 Months From Approved
Responses	1,200	0	0
Time Burden (Hours)	170	0	0
Cost Burden (Dollars)	15,600	0	0

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Abstract: On Sept. 9, 2021, President Biden issued two Executive Orders outlining vaccine requirements for civil servants and contractors. Executive Order (EO) 14043 lays out the requirement for federal employees to become fully vaccinated by November 22, 2021, unless they seek and are granted one of the limited exceptions required by law. The National Aeronautics and Space Administration is establishing specific protocols for ensure its workforce is fully vaccinated people to comply with EO 14043. Individuals are requested to disclose that they are fully vaccinated. Employees may request a reasonable accommodation based on a medical condition. In addition, employees may request a medical deferral to the vaccine requirement if they meet the requirements set forth in the SAFER Workforce Guidance. NASA is committed to granting all exceptions required by law and will accommodate the employee unless to do so would constitute an undue burden on the Agency. NASA Form NF-1699C Request for Medical Exception is designed to collect employee information necessary to ensure the employee has submitted sufficient supporting information and documentation needed for the agency team to adjudicate the request. The information requested on NF 1699C is protected personal information (PII) and is only accessible to individuals with a need to know. The employee submits their reasonable accommodation request through their Center Office of Diversity and Equal Opportunity (ODEO) and the center team works with the employee to ensure the employee has submitted sufficient supporting information and documentation needed for the request.

Emergency Justfication: Pursuant to Office of Management and Budget (OMB) procedures established at 5 C.F.R. Part 1320, Controlling Paperwork Burdens on the Public, I request that the proposed information collection, the NASA Certification of Vaccination, OMB Control No. 2700-NEW, be processed as an Emergency Clearance Request in accordance with 5. C.F.R. § 1320.13, Emergency Processing. I have determined that this information must be collected prior to the time periods established under Part 1320 of the regulations and that this information is essential to implement agencies’ health and safety measures included within recent Centers for Disease Control and Prevention and Safer Federal Workforce Task Force Guidance. Government agencies have an urgent need to request attestation of vaccination status from individuals entering Federal buildings and workspaces. Applying regular Paperwork Reduction Act clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission. As this request for approval concerns an urgent safety need, NASA is seeking OMB’s approval to waive the need for the Federal Register Notices otherwise required by 5 C.F.R. 1320.5(a)(1)(iv) and 1320.8(d)(1) prior to publication and implementation of this disclosure.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
   EO: EO 13994 Name/Subject of EO: Ensuring a Data-Driven Response to COVID-19 and Future High-Consequence Public Health Threats
   US Code: 29 USC 791 Name of Law: Employment of individuals with disabilities
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
NASA COVID-19 Vaccine Exception NASA Form (NF) 1699C Request for Medical Exception	NF-1699C	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,200	0	0	1,200	0	0
Annual Time Burden (Hours)	170	0	0	170	0	0
Annual Cost Burden (Dollars)	15,600	0	0	15,600	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection.

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Annual Cost to Federal Government: $1,080

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/08/2021

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