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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DOC Request for Medical Exemption Form	Form and Instruction	New	Repair queued
DOC Medical Exception Request Form 102621.pdf	Supplementary Document	Uploaded 2021-10-26	Repair queued
Supporting Statement Part A -Emergency ICR COVID 19 Medical Exemption Form 10 25 2021.docx	Supporting Statement A	Uploaded 2021-10-26	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249905	DOC Request for Medical Exemption Form	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202110-0690-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOC/OS	Agency Tracking No:
Title: Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form
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: 10/27/2021
Date Submitted to OIRA: 10/26/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	1,000	0
Time Burden (Hours)	167	0
Cost Burden (Dollars)	0	0

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Abstract: Consistent with Executive Order 14043, of September 9, 2021, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, and included within the Safer Federal Workforce Task Force Guidance mandating all Federal employees be vaccinated by November 22, 2021, the Department of Commerce (DOC) has established specific safety protocols for individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who are not fully vaccinated against COVID-19 by November 22, 2021, or who choose not to provide this information will be required to comply with applicable OMB. OPM and DOC guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements. DOC employees may request an exemption on the basis of a medical condition or circumstance. Exemptions will be granted in limited circumstances and only where legally required. The Medical Exemption Form will be provided directly to the individuals who are requesting a medical exemption.

Emergency Justfication: DOC is seeking approval of the form, “Request for a Medical Exemption Form to the COVID-19 Vaccination Requirement,” which will be completed by employees who seek a medical exemption. DOC seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing. The Form will be used by DOC staff and provided to employees to ensure they submit adequate information to support the exemption request. This form will also ensure the information collected is consistent among the components and minimize the need to seek additional evidence. Rendered decisions should be in accordance with guidelines established by the Safer Federal Workforce Task Force Guidance.

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  

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
DOC Request for Medical Exemption Form		DOC Request for a Medical Exemption Form

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ICR Summary of Burden

table that charts list of burden

	Total Request	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	1,000	0	0	1,000	0	0
Annual Time Burden (Hours)	167	0	0	167	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: $247,432

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: 10/26/2021

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