Form TBD EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEP

EPA MEDICAL CERTIFICATION FOR COVID-19 VACCINATION EXCEPTION REQUEST

Employee Name:		Program/Region:
Employee Pay System-Series-Grade: (e.g., GS-0343-12)		Employee Position Title: (e.g., Program Analyst, Inspector, etc.)
Employee Email Address:		Employee Phone Number:
Employee’s 1st Line Supervisor Name:		Supervisor Email Address:

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 agency 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. The agency will be required to keep confidential any medical information provided, subject to the Rehabilitation Act and Privacy Act standards. Employees who receive an exception or a delay from the vaccination requirement would instead comply with alternative health and safety protocols.

Submitting 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.

All requests for medical exceptions will require medical certification from the employee’s medical provider. Employees are encouraged to use pages 3-4 of this form to collect the required information from their medical provider. The use of this form is not mandatory, but is strongly encouraged for those requesting a medical exception to the vaccine requirement. The form ensures the employee provides the information necessary to adjudicate their request. The agency may ask for other information as needed to determine if you are legally entitled to an exception.

GINA Notice:

The Genetic Information and Nondiscrimination Act of 2008 (GINA) prohibits EPA and other entities covered by GINA Title II from requesting or requiring genetic information of employees or their family members. In order to comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information,” as defined by GINA, includes an individual’s family medical history, the results of an individual’s or family member’s genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.

Privacy Act Statement:

Authority: EPA is authorized to collect the information requested on this form pursuant to: Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sept. 9, 2021); Executive Order 14042, Ensuring Adequate COVID Safety Protocols for Federal Contractors (Sept. 9, 2021); Executive Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980); 5 U.S.C. chs. 63, 79 ; 29 U.S.C. § 654, 29 U.S.C. § 668, 42 U.S.C. § 247d, 44 U.S.C. § 3101, 42 U.S.C. § 12101, 5 CFR Part 339, and 29 CFR Part 1602; Section 501 Rehabilitation Act of 1973; the Americans with Disabilities Act Amendments Act of 2008 (Pub. L. 110-325 (ADAAA); Executive Order 13164, Establishing Procedures to Facilitate the Provision of Reasonable Accommodation, (October 20, 2000); and Equal Employment Opportunity Commission (EEOC) reasonable accommodation regulations and guidance.

Purpose: This information is requested to promote the safety of Federal buildings and the health and safety of the Federal workforce consistent with the above-referenced authorities, the Vaccinations FAQs, Federal Contractors FAQs, and COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance from the Centers for Disease Control and Prevention and the Occupational Safety and Health Administration. Requesting a reasonable accommodation is a voluntary process. The information collected on this form is used to facilitate the reasonable accommodation process for individuals seeking a medical exemption to the COVID-19 vaccination requirement for federal employees.

Routine Use: This information may be disclosed to Agency employees with a need to know, and, per the routine uses found in the system of records notice associated with this collection of information, EPA-73, Reasonable Accommodation Management System (RAMS), 84 FR 32456 (Jul 8, 2019), available at https://www.regulations.gov/document/EPA-HQ-OEI-2017-0536-0001. EPA General routine uses A, B, C, F, I, J, K apply. Please refer to Amendment to General Routine Uses for information about routine use https://www.federalregister.gov/documents/2008/01/14/E8-445/amendment-to-general-routine-uses. For example, Routine Use disclosures may be made include, but are not limited to, the following: adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent necessary to carry out their authorized duties regarding administrative proceedings; to contractors, grantees, or volunteers as necessary to perform their duties for the Federal Government; and as necessary and relevant in the course of litigation or for law enforcement purposes.

Voluntary Disclosure and Consequence for Failure to Provide Information : Providing this information is voluntary. If an employee or applicant does not provide the necessary information, including medical information then a decision-maker may deny the reasonable accommodation/medical exception request. Unless granted an exception, as authorized under the law, https://www.saferfederalworkforce.gov/faq/vaccinations/, all covered Federal employees are required to be vaccinated against COVID-19 and to provide documentation concerning their vaccination status to their employing agency.

Employee Name:
Medical Provider Name:
Medical Provider Title:

The Environmental Protection Agency (EPA) 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 exception to the requirement for COVID-19 vaccination or a delay because of a temporary condition or medical circumstance. Please complete this form to assist EPA in its reasonable accommodation process.

Please provide at least the following information, where applicable (you may attach additional sheets, if necessary):

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.
3. Any other medical condition that would limit the employee from receiving any COVID-19 vaccine.
4. Description of the medical condition for which the employee listed above should be excepted from complying with a COVID-19 vaccination requirement.
5. The condition described above is:
Temporary	Long-term
6. 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):
7. Any additional information you determine is important to consider.

Medical Provider Signature: ______________________________ Date: _______________

*Handwritten or electronic signatures are acceptable.

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