Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DL1-7071 Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction	New	Repair queued
DOL Medical Exemption Emergency Memo Signed 11.15.21.pdf	Supplementary Document	Uploaded 2021-11-15	Repair queued
DOL Medical Exemption Emergency SS 11.15.21.docx	Supporting Statement A	Uploaded 2021-11-15	Repair queued
OPM GOVT-10 SORN.pdf	Supplementary Document	Uploaded 2021-11-12	Repair queued
DOL_CENTRAL-6 _ SORN.pdf	Supplementary Document	Uploaded 2021-11-12	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250283	Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-1225-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: DOL/DM	Agency Tracking No:
Title: Request for a Medical Exception or Delay to the 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: 11/18/2021
Date Submitted to OIRA: 11/15/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	250	0
Time Burden (Hours)	42	0
Cost Burden (Dollars)	0	0

---

Abstract: This information is being requested to promote the federal workforce, the safety of federal buildings, and others on site at agency facilities or those interacting with the public consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the CDC. To request a medical exemption from the COVID-19 vaccination requirement, an employee must complete Section I of the medical exemption form, and their medical provider must complete Sections II and III.

Emergency Justfication: This information is essential to implement agencies’ health and safety measures included within recent Centers for Disease Control and Prevention and Safer Federal Workforce Task Force Guidance. The Department of Labor (DOL) has an urgent need to collect information for individuals applying for medical exemption to the COVID-19 Mandatory Vaccinations and this medical exemption form is necessary for DOL to determine legal exemptions to the vaccine requirement under the Rehabilitation Act and Americans with Disabilities Act. Applying regular Paperwork Reduction Act (PRA) clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission.

---

Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
   US Code: 29 USC 791 Name of Law: The Rehabilitation Act of 1973
  

Citations for New Statutory Requirements: EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination Requirement	DL1-7071	Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement

---

ICR Summary of Burden

table that charts list of burden

	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	250	0	250	0	0	0
Annual Time Burden (Hours)	42	0	42	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

---

Annual Cost to Federal Government: $0

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

---

Common Form ICR:  No

---

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: 11/15/2021

---