Request for Medical Exception to COVID-19 Vaccination Requirement

ICR 202111-1212-001

OMB: 1212-0075

Federal Form Document

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ICR Details
1212-0075 202111-1212-001
Request for Medical Exception to COVID-19 Vaccination Requirement
New collection (Request for a new OMB Control Number)   No
Emergency 11/23/2021
Approved without change 11/23/2021
Retrieve Notice of Action (NOA) 11/23/2021
  Inventory as of this Action Requested Previously Approved
05/31/2022 6 Months From Approved
5 0 0
3 0 0
0 0 0

Executive Order 14043 requires every Federal agency to “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.” In following this directive, the Pension Benefit Guaranty Corporation (PBGC) issued a requirement that its employees must receive and submit proof of a COVID-19 vaccination. Also, following the requirement in Executive Order 14043 to allow exceptions to the COVID-19 vaccination requirement as required by law, PBGC is allowing an exception from the vaccination requirement for employees due to medical reasons or disabilities that would make the COVID-19 vaccine unsafe for them. To ensure that PBGC has the information to determine whether a medical exception for an employee is legally required, PBGC is providing a form to obtain information to help determine an employee’s entitlement to the exception.
PBGC requests emergency processing and waiver of the public notice requirements for this ICR under 5 CFR § 1320.13. Delaying approval of this ICR would be contrary to the directives in Executive Order 14043 and the Safer Federal Workforce Task Force guidance that all agency employees, unless entitled to a legally required exception, must be vaccinated by November 22, 2021. The agency’s ability to ensure a safe work environment for its employees, and to ensure employees entitled to an exception are provided with that exception, would be hindered.


Not associated with rulemaking


  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 5 0 0 5 0 0
Annual Time Burden (Hours) 3 0 0 3 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
This request is for a new ICR made necessary by Executive Order 14043.

Melissa Rifkin 202 326-4400 [email protected]


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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