SUPPORTING STATEMENT - PART A
Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement – OMB Control Number 0704-DMEF
1. Need for the Information Collection
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 Defense (DoD) 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 DoD 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.
DoD civilian employees may request an exemption on the basis of a medical condition or circumstance or a sincerely held religious belief, practice or observance. Exemptions will be granted in limited circumstances and only where legally required.
2. Use of the Information
DoD is seeking approval of DD Form 3176, “Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement,” which will be completed by employees who seek a medical exemption. DoD seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing. The DD Form 3176 will be used by DoD 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.
DoD issued Force Health Protection Guidance (FHP), Supplement 23 on September 7, 2021, and Revision 1 thereto on October 18, 2021, in response to OMB and OPM guidance. FHP 23 Revision 2 which includes the process for requesting either a medical or religious exemption is currently being coordinated and expected to be signed and published on October 22, 2021. DoD will provide OMB a copy of the FHP 23 Revision 2 once it is approved and published. The DD Form 3176 will be provided directly by the individuals who is requesting a medical exemption. In establishing exemption processes, Heads of DoD Components, the Director of Administration and Management (for the Office of the Secretary of Defense Components, the Chairman of the Joint Chiefs of Staff, the Defense Agencies, and DoD Field Activities), and the Commanders of the Combatant Commands will ensure that the management official(s) who are designated to make decisions concerning requests for exemption from COVID-19 vaccination make such decisions in coordination with the organization’s servicing legal office and are at an appropriate level within the organization to consider the impact, if any, of the volume of requests and to ensure that similar cases are handled in a consistent manner.
3. Use of Information Technology
DD Form 3176 will be available on the DoD Forms Website. It will be fillable with the ability to digitally sign and submit electronically via email. An estimated 75% of respondents will be submitting the form electronically.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
6. Less Frequent Collection
It is anticipated that the respondent will only need to provide this information one time, so there is no way to change the frequency without compromising the results of this collection.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
Emergency approval was received to waive the public notice requirement under the Paperwork Reduction Act.
Part B: CONSULTATION
Aside from discussions with Office of Management and Budget (OMB) personnel, no additional consultation was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
The Privacy Act Statement is provided near the top of the form provided to the respondent.
The Systems of Records Notices (SORNs) associated with this data collection is as follows:
DoD 0007, Defense Reasonable Accommodations and Assistive Technology Records, 86 Fed. Reg. 38692 (July. 22, 2010)- also available at https://www.govinfo.gov/content/pkg/FR-2021-07-22/pdf/2021-15601.pdf
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
11. Sensitive Questions
The questions included on this form are consistent with OMB’s guidance for requesting a medical exemption.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
Collection Instrument(s)
[DD Form 3176]
Number of Respondents: 180,000
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 180,000
Response Time: 5 minutes
Respondent Burden Hours: 15,000 hours
Total Submission Burden
Total Number of Respondents: 180,000
Total Number of Annual Responses: 180,000
Total Respondent Burden Hours: 15,000 hours
Part B: LABOR COST OF RESPONDENT BURDEN
Collection Instrument(s)
[DD Form 3176]
Number of Total Annual Responses: 180,000
Response Time: 5 minutes
Respondent Hourly Wage: $27.07
Labor Burden per Response: $2.25
Total Labor Burden: $405,000
Overall Labor Burden
Total Number of Annual Responses: 180,000
Total Labor Burden: $405,000
The Respondent hourly wage was determined by using the Department of Labor Wage Website ([http://www.dol.gov/dol/topic/wages/index.htm])
13. Respondent Costs Other Than Burden Hour Costs
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
Collection Instrument(s)
[DD Form 3176]
Number of Total Annual Responses: 180,000
Processing Time per Response: 1 hour
Hourly Wage of Worker(s) Processing Responses: $27.07
Cost to Process Each Response: $27.07
Total Cost to Process Responses: $4,872,600
Overall Labor Burden to the Federal Government
Total Number of Annual Responses: 180,000
Total Labor Burden: $4,872,600
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0.00
Printing: $280,000
Postage: $0.00
Software Purchases: $0.00
Licensing Costs: $0.00
Total Operational and Maintenance Cost: $280,000
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total estimated costs for the DoD include labor costs and potential printing of the DD Forms 3176 (for those that are not able to access computers).
Total Labor Cost to the Federal Government: $4,872,600
Total Operational and Maintenance Costs: $280,000
Total Cost to the Federal Government $5,152,600
15. Reasons for Change in Burden
This is a new collection with a new associated burden.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
DoD is not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
DoD is not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2021-10-20 |