EPA Medical Certification for Covid-19 Vaccination Exception Request.

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TBD EPA Medical Certification for Covid-19 Vaccination Exception Request.	Form	New	Repair queued
11-23-2021 - EPA ICR Supporting Statement - 2704ss01.docx	Supporting Statement A	Uploaded 2021-11-23	Repair queued
11-23-2021 - EPA ICR Memo Emergency Request.pdf	Supplementary Document	Uploaded 2021-11-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250500	EPA Medical Certification for Covid-19 Vaccination Exception Request.	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202111-2030-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: EPA/OMS	Agency Tracking No: 2704.01
Title: EPA Medical Certification for Covid-19 Vaccination Exception Request.
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: 11/24/2021
Date Submitted to OIRA: 11/23/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	175	0
Time Burden (Hours)	175	0
Cost Burden (Dollars)	0	0

---

Abstract: Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (September 9, 2021), 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. In order to make determinations on requests for medical exceptions to the vaccine mandate, EPA needs to collect information, including medical certification from the employee’s medical provider to support their request for accommodation. This information is essential to implement health and safety measures requiring all Federal employees be vaccinated against COVID-19.

Emergency Justfication: Pursuant to section 3507(j) of the Paperwork Reduction Act (PRA) (44 U.S.C. 3501 et seq.), as implemented in the Office of Management and Budget (OMB) regulations at 5 CFR §1320.13, the Environmental Protection Agency (EPA) is hereby requesting emergency processing of an information collection necessary for collecting information from individuals applying for medical exemption to the COVID-19 Mandatory Vaccinations. Given the critical role of the collection of information to meeting our commitments as outlined in Executive Order (E.O.) 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees and the Safer Federal Workforce Task Force guidance, EPA cannot reasonably comply with the normal clearance procedures.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

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
EPA Medical Certification for Covid-19 Vaccination Exception Request.	TBD	EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEPTION REQUEST

---

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	175	0	0	175	0	0
Annual Time Burden (Hours)	175	0	0	175	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 is a new ICR.

---

Annual Cost to Federal Government: $30,870

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? No

---

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: 11/23/2021

---