1000 Request for a Medical Exception to the COVID-19 Vaccinat

FEDERAL ENERGY REGULATORY COMMISSION

FERC Form No. 1000

OMB Control No. 1902-NEW, Expiration Date: TBD

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 22, 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 Investigation Files,” 65 FR 21742 (April 24, 2000), amended, 86 FR 64923 (November 19, 2021).

Consequence of Failure to Provide Information: If you are seeking a medical or religious exception to the requirement that you be vaccinated for the COVID-19 virus, providing the requested information is voluntary, but failure to provide the information could adversely affect how the Commission acts on the request for accommodation. 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.

Paperwork Reduction Act Materials

The purpose of FERC Form No. 1000 is to allow the Federal Energy Regulatory Commission to collect information from individuals applying for a medical exception to the COVID-19 Vaccination Requirement.  The collection of information is critical to meeting the requirements outlined in Executive Order 14043 (on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees) and the Safer Federal Workforce Task Force requirements and guidance. 

The public reporting burden for this information collection (FERC-1000) is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining the data-needed, and completing and reviewing the collection of information.  Although responses are voluntary, failure to provide the information could adversely affect how the Commission acts on the request for accommodation.  You may send comments on the burden estimate or any aspect of the collection of information, to the Federal Energy Regulatory Commission at [email protected]; and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, DC 20503 through www.reginfo.gov/public/do/PRAMain, Attention:  Federal Energy Regulatory Commission Desk Officer (and include the OMB Control No.).  No person shall be subject to any penalty if any collection of information does not display a valid OMB Control Number (44 U.S.C. § 3512 (a)).

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: 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; 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 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:	temporary long-term
Medical Provider Name/Title