Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form

ICR 202111-2105-001

OMB: 2105-0577

Federal Form Document

IC Document Collections
ICR Details
202111-2105-001
Received in OIRA
DOT/OST
Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form
New collection (Request for a new OMB Control Number)   No
Emergency 11/24/2021
11/23/2021
  Requested Previously Approved
04/30/2022
4,000 0
8,000 0
2,320 0

Consistent with Executive Order 14043, of September 9, 2021, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees”, and included within the Safer Federal Workforce Task Force Guidance mandating all Federal employees be vaccinated by November 22, 2021, the Department of Transportation (DOT) has established specific safety protocols for individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who are not fully vaccinated against COVID-19 by November 22, 2021, or who choose not to provide this information will be required to comply with applicable OMB. OPM and DOT guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements. DOT civilian employees may request an exception on the basis of a medical condition or circumstance or a sincerely held religious belief, practice or observance. Exceptions will be granted in limited circumstances and only where legally required.
Because of the nature of the public health emergency and the urgent need for the Department to have all Federal employees vaccinated, except those approved under a medical or religious exemption, it is impracticable for DOT to consult in advance with interested agencies and members of the public in order to minimize the burden of the collection of information pursuant to 5 C.F.R. 1320.13(c). Therefore, DOT requests a 180-day emergency clearance to obtain the information required in DD Form 3176, "Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement"

None
None

Not associated with rulemaking

No

  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 4,000 0 0 4,000 0 0
Annual Time Burden (Hours) 8,000 0 0 8,000 0 0
Annual Cost Burden (Dollars) 2,320 0 0 2,320 0 0
Yes
Changing Regulations
No
This is a new collection for an emergency processing request for the Request for Medical Exemption to COVID-19 Vaccination Requirement Form.

$247,500
No
    Yes
    Yes
No
No
No
Yes
Yvette Rivera 202 366-4648

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
11/23/2021


© 2021 OMB.report | Privacy Policy