COVID-19 Vaccine Supplemental Medical Provider Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement	Form	New	Available
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement	Form	New	Repair queued
SS Part A -Emergency ICR COVID 19 Medical Exemption20211109.docx	Supporting Statement A	Uploaded 2021-11-10	Repair queued
E.O. 14043 COVID 20210914.pdf	Supplementary Document	Uploaded 2021-11-09	Repair queued
Information Quality Guidelines _ USPTO.pdf	Supplementary Document	Uploaded 2021-11-08	Repair queued
OMB Emergency Memo Final 20211108.pdf	Supplementary Document	Uploaded 2021-11-08	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250233	COVID-19 Vaccine Supplemental Medical Provider Statement	Form	New	COVID-19 Vaccine Supplemental Medical Provider Statement
250233	COVID-19 Vaccine Supplemental Medical Provider Statement	Form	New

ICR Details

OMB Control No: 0651-0087	ICR Reference No: 202111-0651-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOC/PTO	Agency Tracking No:
Title: COVID-19 Vaccine Supplemental Medical Provider Statement
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
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/12/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/10/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	6 Months From Approved
Responses	150	0	0
Time Burden (Hours)	25	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

Emergency Justfication: 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.

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirius 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
COVID-19 Vaccine Supplemental Medical Provider Statement	USPTO-OEEOD 303	COVID-19 Vaccine Supplemental Medical Provider Statement

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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

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 information collection.

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Annual Cost to Federal Government: $26,459

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: 11/10/2021

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