Form FERC Form No. 1000 FERC Form No. 1000 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT

FEDERAL ENERGY REGULATORY COMMISSION
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Government-wide policy requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated
against COVID-19, with exceptions only as required by law. Employees may seek a legal exception to the
vaccination requirement due to a disability, using the form below. The Federal Energy Regulatory
Commission (FERC) may also ask for other information, as needed. Requests for “medical accommodation”
or “medical exceptions” will be treated as requests for a disability accommodation and evaluated and
decided under applicable Rehabilitation Act standards for reasonable accommodation absent undue
hardship to the agency. An employee may also request a delay for complying with the vaccination
requirement based on certain medical considerations that may not justify an exception under the
Rehabilitation Act. Safer Federal Workforce Task Force guidance on medical considerations that may
warrant a delay is available here. FERC will be required to keep confidential any medical information
provided, subject to the applicable Rehabilitation Act standards. Employees who receive an exception or a
delay from the vaccination requirement would instead comply with alternative health and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best
of your knowledge and ability. Any intentional misrepresentation to the Federal Government may result in
legal consequences, including termination or removal from Federal Service.
To request a medical exception or delay from the COVID-19 vaccination requirement using this form:

1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, you must submit the form to

[email protected] no later than November 8, 2021.

Privacy Act Statement Authority:
Authority: Pursuant to Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal
Employees (Sept. 9, 2021), we are authorized to collect this information.
Purpose: This information is being collected and maintained to promote the safety of Federal workplaces and
the Federal workforce consistent with the above-referenced authority Executive Order 14043, which requires
mandatory vaccinations for all federal employees with exceptions only as required by law.
Routine Uses: While the information requested is intended to be used primarily for internal purposes, in certain
circumstances it may be necessary to disclose this information externally, for example to disclose information to:
a Federal, State, or local agency to the extent necessary to comply with laws governing reporting of
communicable disease or other laws concerning health and safety in the work environment; to adjudicative
bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent necessary to
carry out their authorized duties regarding Federal employment; to contractors, grantees, or volunteers as
necessary to perform their duties for the Federal Government; to other agencies, courts, and persons as
necessary and relevant in the course of litigation, and as necessary and in accordance with requirements for law
enforcement; or to a person authorized to act on your behalf. A complete list of the routine uses can be found in
the SORN associated with this collection of information, FERC-24 Commission Miscellaneous.
Consequence of Failure to Provide Information: If you are requesting a medical or religious exception to the
requirement that you be vaccinated for the COVID-19 virus, providing the requested information is mandatory.
Unless granted a legally required exception, all covered Federal employees are required to be vaccinated against
COVID-19 and to provide documentation concerning their vaccination status to their employing agency. Unless
you have been granted a legally required exception, failure to provide this information may subject you to
disciplinary action, including and up to removal from Federal service.

Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Program Office

Division /Branch

Position Title

Phone Number

Supervisor's Name

Medical or Disability Exception Request
I am requesting a medical exception to the requirement for COVID-19 vaccination or a delay because
of a temporary condition or medical circumstance. I declare that the information I have provided is
true and correct to the best of my knowledge and ability.

Employee Signature

Print Name

Date

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The Federal Energy Regulatory Commission (FERC) requires its employees to be fully vaccinated
against COVID-19 pursuant to Executive Order of the President of the United States. The individual
named above is seeking a medical exemption to the requirement for COVID-19 vaccination or a delay
because of a temporary condition or medical circumstance. Please complete this form to assist FERC
in its reasonable accommodation process. If you have questions about completing this form, please
contact Ms. Kadia Givner, FERC’s Reasonable Accommodation Program Manager at
[email protected].
Please provide at least the following information, where applicable:
1. The applicable contraindication or precaution for COVID-19 vaccination, and for each
contraindication or precaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether it is listed in the package insert or Emergency Use Authorization fact
sheet for each of the COVID-19 vaccines authorized or approved for use in the United States;
2. A statement that the individual’s condition and medical circumstances relating to the
individual are such that COVID-19 vaccination is not considered safe, indicating the specific
nature of the medical condition or circumstances that contraindicate immunization with a
COVID-19 vaccine or might increase the risk for a serious adverse reaction; and
3. Any other medical condition that would limit the employee from receiving any COVID-19
vaccine.
Please have your physician provide the information requested above on their letterhead with
their signature including their basis for any conclusion on restrictions or accommodations that
are, or are not warranted. If this is a temporary condition or medical circumstance, when it is
expected to end or expire (allowing for COVID-19 vaccination to begin after the date you
provided)?
The condition described above is:
Medical Provider Name/Title

temporary

long-term