Form AID 111-9 AID 111-9 U.S. Personal Services Contractor Request for a Medical

U.S. PERSONAL SERVICES CONTRACTOR REQUEST
FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Government-wide policy requires all USAID Personal Services Contractors (PSC) to be vaccinated
against COVID-19, with exceptions only as required by law. Contractors may seek an exception to the
vaccination requirement due to a disability, using the form below. The agency may also ask for other
relevant information, as needed. Requests for “medical accommodation” or “medical exceptions” will be
treated as requests for a disability accommodation and evaluated and decided under applicable
Rehabilitation Act standards for reasonable accommodation absent undue hardship to the agency. A
contractor may also request a delay for complying with the vaccination requirement based on certain
medical considerations that may not justify an exception under the Rehabilitation Act. Safer Federal
Workforce Task Force guidance on medical considerations that may warrant a delay is available here. The
agency will be required to keep confidential any medical information provided, subject to the applicable
Rehabilitation Act standards. Contractors who receive an exception or a delay from the vaccination
requirement would instead comply with alternative health and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best
of your knowledge and ability. Any intentional misrepresentation to the Federal Government may result in
legal and administrative consequences, up to and including termination of your contract.
To request a medical exception or delay from the COVID-19 vaccination requirement using this form:
1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, you must submit the form to your agency’s designated point of contact.
Privacy Act Statement

Authority: In discharging the functions directed under Executive Order 14042 on Ensuring
Adequate COVID Safety Protocols for Federal Contractors, we are authorized to collect this information.
The authorities for the system of records notices (SORNs) associated with this collection of information,
USAID-32, Reasonable Accommodation Records, 81 FR 70085 (October 11, 2016) and USAID-34,
Personal Services Contracts Records, 80 FR 11391 (March 3, 2015). Providing this information is
mandatory, and we are authorized to impose penalties for failure to provide the information pursuant to
applicable Federal personnel laws and regulations.
Purpose: This information is being collected and maintained to promote the safety of Federal workplaces
and the Federal workforce consistent with the above-referenced authorities, Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the COVID-19
Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task
Force, and guidance from Centers for Disease Control and Prevention and the Occupational Safety and
Health Administration.

Routine Uses: While the information requested is intended to be used primarily for internal purposes, in
certain circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work environment;
to adjudicative bodies, arbitrators, and hearing examiners to the extent necessary to carry out their
authorized duties regarding Federal contractors; to other agencies, courts, and persons as necessary and
relevant in the course of litigation, and as necessary and in accordance with requirements for law
enforcement; or to a person authorized to act on your behalf. A complete list of the routine uses can be
found in the SORN associated with this collection of information, USAID-32, Reasonable
Accommodation Records, 81 FR 70085 (October 11, 2016) USAID-34, Personal Services Contracts
Records, 80 FR 11391 (March 3, 2015).
Consequence of Failure to Provide Information: Providing this information is mandatory. Unless
granted a legally required exception, all covered Federal contractors are required to be vaccinated against
COVID-19 and to provide documentation concerning their vaccination status to their employing agency.
Unless you have been granted a legally required exception, failure to provide this information may result
in the termination of your contract or other remedies.

Part 1 – To Be Completed by the USPSC
USPSContractor or Apparently Successful Offeror Name

Date of Request

Mission/Bureau/Independent Office/Division

Position

Supervisor or PSC Recruiter

Contracting Officer (CO)

Phone Number

Medical or Disability Exception Request
I am requesting a medical exception to the requirement for COVID-19 vaccination or a delay because
of a temporary condition or medical circumstance. I declare that the information I have provided is true
and correct to the best of my knowledge and ability.
USPSC or Apparently Successful Offeror Signature

Print Name

Date

Part 2 – To be Completed by the USPSC’s Medical Provider
USPSC or Apparently Successful Offeror Name

Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The U.S. Agency for International Development (USAID) requires its covered Federal contractors to
be fully vaccinated against COVID-19 pursuant to Executive Order of the President of the United
States. The individual named above is seeking a medical exception to the requirement for COVID-19
vaccination or a delay because of a temporary condition or medical circumstance. Please complete this
form to assist USAID in its reasonable accommodation process. If you have questions about
completing this form, please contact USAID’s reasonable accommodation coordinator at
[email protected].
Please provide at least the following information, where applicable:
1. The applicable contraindication or precaution for COVID-19 vaccination, and for each
contraindication or precaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether it is listed in the package insert or Emergency Use Authorization
fact sheet for each of the COVID-19 vaccines authorized or approved for use in the United
States;
2. A statement that the individual’s condition and medical circumstances relating to the individual
are such that COVID-19 vaccination is not considered safe, indicating the specific nature of the
medical condition or circumstances that contraindicate immunization with a COVID-19
vaccine or might increase the risk for a serious adverse reaction; and
3. Any other medical condition that would limit the covered Federal contractor from receiving
any COVID-19 vaccine.
Description of the medical condition for which the covered Federal contractor listed above should be
excepted from complying with a COVID-19 vaccination requirement:

The condition described above is:

Temporary
Long-Term

If this is a temporary condition or medical circumstance, when it is expected to end or expire (allowing
for COVID-19 vaccination to begin after the date you provided):

Medical Provider Name/Title

Medical Provider Signature

Date