COVID-19 Vaccine Supplemental Medical Provider Statement

ICR 202111-0651-001

OMB: 0651-0087

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
Received in OIRA
COVID-19 Vaccine Supplemental Medical Provider Statement
New collection (Request for a new OMB Control Number)   No
Emergency 11/12/2021
  Requested Previously Approved
6 Months From Approved
150 0
25 0
0 0

Consistent with guidance from the Centers for Disease Control and Prevention (CDC), guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991 of January 20, 2021, Protecting the Federal Workforce and Requiring Mask-Wearing, and Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, the request for this collection of information is essential to implement the USPTO’s health and safety measures regarding the Federal employee medical exemptions to the COVID-19 mandatory vaccinations. The Rehabilitation Act of 1973, as amended, requires Federal agencies to provide reasonable accommodations to qualified employees with disabilities unless that reasonable accommodation would impose an undue hardship on the employee’s agency. See 29 U.S.C. 791; 29 CFR Part 1614; see also 20 CFR Part 1630 and Executive Order 13164 of July 26, 2000, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation. Section 2 of E.O. 14043 mandates that each agency “implement, to the extent consistent with applicable law, a program to require COVID-19 vaccination for all of its Federal employees, with exceptions only as required by law.” This COVID-19 Vaccine Supplemental Medical Provider Statement is necessary for USPTO to determine legal exemptions to the vaccine requirement under the Rehabilitation Act.
Pursuant to Office of Management and Budget (OMB) procedures established at 5 CFR Part 1320, Controlling Paperwork Burdens on the Public, the U.S. Patent and Trademark Office (USPTO) requests that the proposed information collection, the COVID-19 Vaccine Supplemental Medical Provider Statement, OMB Control Number 0651-NEW, be processed as an Emergency Clearance Request in accordance with 5 CFR § 1320.13, Emergency Processing. USPTO has 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 regarding the Federal employee medical and religious exemptions to the vaccination requirement included within recent Safer Federal Workforce Task Force Guidance for COVID-19 Mandatory Vaccinations. Government agencies have an urgent need to request medical exemption information with input from medical providers for federal employees. Applying regular Paperwork Reduction Act clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission (5 CFR § 1320.13(c)). Therefore, the USPTO requests a 180-day emergency clearance to establish the COVID-19 Vaccine Supplemental Medical Provider Statement, allowing individuals to request medical exemptions, with medical provider input, from COVID-19 Mandatory Vaccinations. During the 180-day emergency approval, the USPTO will work to establish a regular clearance submission of this information collection request under the Paperwork Reduction Act procedures. As this request for approval concerns an urgent safety need, USPTO is also seeking OMB’s approval to waive the need for the Federal Register Notices otherwise required by 5 CFR § 1320.5(a)(1)(iv) and 1320.8(d)(1) prior to publication and implementation of this disclosure. USPTO would appreciate if OMB could provide an approval/disapproval determination of this request to collect information under an emergency clearance by close of business on Friday, November 12, 2021.

EO: EO 14043 Name/Subject of EO: Requiring Coronavirius Disease 2019 Vaccination for Federal Employees

Not associated with rulemaking


IC Title Form No. Form Name
COVID-19 Vaccine Supplemental Medical Provider Statement USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement

  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 150 0 0 150 0 0
Annual Time Burden (Hours) 25 0 0 25 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
This is a new information collection.

Naveen Paul 571 270-5395


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:
    (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;
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.

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