Request for Medical Exception to COVID-19 Vaccination Requirement

Forms and Documents

Document Name	Status
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement Form and Instruction	New
SFA IFR Emergency Memo.2.docx Supplementary Document	2021-11-23
Vaccine Requirement Exemption ICR Supporting Statement.04.docx Supporting Statement A	2021-11-23

IC Document Collections

IC ID	Document Title	Status
250509	Request for Medical Exception to COVID-19 Vaccination Requirement Form and Instruction	New

ICR Details

OMB Control No: 1212-0075	ICR Reference No: 202111-1212-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: PBGC	Agency Tracking No:
Title: Request for Medical Exception to 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: 11/23/2021
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/23/2021
	Date Received in OIRA: 11/23/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	6 Months From Approved
Responses	5	0	0
Time Burden (Hours)	3	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

Emergency Justfication: 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.

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Authorizing Statute(s): None

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

IC Title	Form No.	Form Name
Request for Medical Exception to COVID-19 Vaccination Requirement	Part I , Part II	Request for Medical Exception to COVID-19 Vaccination Requirement, Part I ,   Request for Medical Exception to COVID-19 Vaccination Requirement

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ICR Summary 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	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

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 request is for a new ICR made necessary by Executive Order 14043.

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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

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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: 11/23/2021

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