U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement

Forms and Documents

Document	Type	Status	Availability
Form AID 111-9 U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement	Form	New	Repair queued
Justification Statement - USPSC Medical Exception Form_signed.pdf	Supplementary Document	Uploaded 2021-11-08	Repair queued
Supporting Statement - USPSC Medical Exception Form.pdf	Supporting Statement A	Uploaded 2021-11-08	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
250242	U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202111-0412-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: AID	Agency Tracking No:
Title: U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement
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: 11/12/2021
Date Submitted to OIRA: 11/08/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	40	0
Time Burden (Hours)	30	0
Cost Burden (Dollars)	0	0

---

Abstract: As required by Executive Order 14042, USAID is implementing the federal COVID-19 vaccination mandate and is considering USPSCs requests for legally-required exceptions or delays to the mandate. In order to process and determine appropriate accommodations for requests for medical exceptions or delays, USAID must collect the medical information necessary for case evaluation. Respondents will be USAID Personal Services Contractors requesting a medical exceptions to the vaccination mandate.

Emergency Justfication: Our request meets the standard for emergency processing as the Agency needs adequate medical information and time to process legally-required medical exceptions to the federal vaccine requirement, and USPSCs must receive their last dose of their vaccine no later than January 4, 2022, to meet the January 18, 2022 deadline to be fully vaccinated. Additionally, the COVID-19 pandemic is an unanticipated event with immediate risks to workforce lives, warranting emergency processing. These forms are critical to USAID's compliance with the federal vaccination mandate and COVID-19 response efforts as we need contractors requesting medical exceptions to obtain verified medical information from their health care provider(s) in order to adequately evaluate contractors for an exception or delay.

---

Authorizing Statute(s): EO: EO 14042 Name/Subject of EO: Ensuring Adequate COVID Safety Protocols for Federal Contractors
   EO: EO 13991 Name/Subject of EO: Executive Order on Protecting the Federal Workforce and Requiring Mask-Wearing
  

Citations for New Statutory Requirements: EO: EO 14042 Name/Subject of EO: Ensuring Adequate COVID Safety Protocols for Federal Contractors

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement	AID 111-9	U.S. Personal Services Contractor Request for a Medical Exception To The Covid-19 Vaccination Requirement

---

ICR Summary 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	40	0	0	40	0	0
Annual Time Burden (Hours)	30	0	0	30	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.

---

Annual Cost to Federal Government:

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

---

Common Form ICR:  No

---

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: 11/08/2021

---