Supporting Statement Part A _Emergency_ Request for Medical Exemption Form_112321

SUPPORTING STATEMENT
U. S. Department of Transportation
Medical Exemption Form
OMB Control No. 2105-NEW

Abstract
The purpose of this emergency request of Paperwork Reduction Act (PRA) clearance is to allow the
Department of Transportation (DOT) to collect information from individuals applying for medical
exemption to the COVID-19 Mandatory Vaccinations as specified in the Agency Medical Exemption
Form, Part 2. Given the critical role of the collection of information to meeting our commitments as
outlined in Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019
Vaccination for Federal Employees and the Safer Federal Workforce Task Force guidance, the DOT
cannot reasonably comply at present with the normal clearance procedures.
Justification
1. Explain the circumstances that make the collection of information necessary. Identify any
legal or administrative requirements that necessitate the collection. Attach a copy of the
appropriate section of each statute and regulation mandating or authorizing the collection of
information.
Consistent with guidance from the Centers for Disease Control and Prevention (CDC), guidance from
the Safer Federal Workforce Task Force established pursuant to Executive Order 13991 of January
20, 2021, Protecting the Federal Workforce and Requiring Mask-Wearing, and Executive Order
14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for
Federal Employees, the request for this collection of information is essential to implement the
Department of Commerce’s health and safety measures regarding the Federal Employee medical
exemptions to the COVID-19 mandatory vaccinations. The Rehabilitation Act of 1973, as amended,
requires Federal Agencies to provide reasonable accommodations to qualified employees with
disabilities unless that reasonable accommodation would impose an undue hardship on the
employee’s Agency. See 29 U.S.C. 791; 29 C.F.R. Part 1614; see also 20 C.F.R. Part 1630 and
Executive Order 13164 of July 26, 2000, Requiring Federal Agencies to Establish Procedures to
Facilitate the Provision of Reasonable Accommodation. Section 2 of E.O. 14043 mandates that each
agency “implement, to the extent consistent with applicable law, a program to require COVID-19
vaccination for all of its Federal employees, with exceptions only as required by law.” This medical
exemption form is necessary for Commerce to determine legal exemptions to the vaccine
requirement under the Rehabilitation Act.
Government agencies have an urgent need to request medical exemption information with input from
medical providers from federal employees. Applying regular Paperwork Reduction Act clearance
procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission (5
C.F.R § 1320.13(c)).

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a
new collection, indicate the actual use the agency has made of the information received from
the current collection.
This information is being requested to promote the Federal workforce, the safety of Federal buildings,
and others on site at agency facilities or those interacting with the public consistent with the COVID19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce
Task Force and guidance from the Centers for Disease Control and Prevention. To request a medical
exemption from the COVID-19 vaccination requirement, an employee must complete Part 1 of the
medical exemption form and their medical provider must complete Part 2.
This would differ from the staff who implements and enforces the safety protocols that will apply to the
unvaccinated employee who is granted the medical exemption. If that designated person is someone
other than the supervisor, they would not receive this form. However, it’s likely that the designated
person would be notified by the supervisor that the employee has an exemption based on medical.
This form will also ensure the information collected is consistent among the Department’s
Components and minimize the need to seek additional evidence.
DOT seeks OMB’s approval to process the form as emergency clearance requests in accordance
with 5 C.F.R. § 1320.13, Emergency Processing.
Table: Information Requirements and Needs and Uses of Information Collected
Item #

Requirement

Executive
Order

Regulation

1

Medical
Exemption
Form

14043

5 C.F.R. §
1320.13

Needs and Uses

•

Used by Federal employee to request medical
exemption from COVID-19 Vaccine Mandates.

•

Used by the Federal employee’s medical
provider for medical certification of COVID-19
Vaccine exemption.

•

Used by DOC staff to process the request and
enforce the COVID-19 Vaccine Mandates.

3. Describe whether, and to what extent, the collection of information involves the use of
automated, electronic, mechanical, or other technological collection techniques or other
forms of information technology, e.g., permitting electronic submission of responses, and the
basis for the decision for adopting this means of collection. Also, describe any consideration
of using information technology to reduce burden.
This information collection will require the individual responder to fill out the required fields of the form
and submit the completed form to the appropriate DOT personnel. A link to this form or a PDF version
may be emailed to respondents who may print it out to complete it or complete it electronically. We
will continue to explore options to use technology to reduce the burden on individuals.
4. Describe efforts to identify duplication. Show specifically why any similar information
already available cannot be used or modified for use for the purposes described in Question 2
We are unaware of other sources of similar information available for use by the respondents.
5. If the collection of information impacts small businesses or other small entities, describe
any methods used to minimize burden.
This information collection request has no identified impact on small businesses and organizations.

6. Describe the consequence to Federal program or policy activities if the collection is not
conducted or is conducted less frequently, as well as any technical or legal obstacles to
reducing burden.
Less frequent collection would inhibit DOT’s ability to meet the mandates of the Safer Federal
Workforce Task Force and DOT’s specific established COVID-19 workplace safety protocols.
7. Explain any special circumstances associated with conducting this information collection.
There are no other special circumstances involved in the collection of this information.
8. If applicable, provide a copy and identify the date and page number of publications in the
Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on
the information collection prior to submission to OMB. Summarize public comments received
in response to that notice and describe actions taken by the agency in response to these
comments. Specifically address comments received on cost and hour burden.
DOT has requested and has been granted a waiver from the requirement to publish a notice in the
Federal Register in connection with a request for emergency clearance of this information collection
request.
Aside from discussions with Office of Management and Budget (OMB) personnel, and other Federal
agencies, no additional consultation was conducted for this submission.
9. Explain any decision to provide any payment or gift to respondents, other than
renumeration of contractors or grantees.
No gifts or payments of any kind have been provided to any individuals who are connected to this
collection.
10. Describe any assurance of confidentiality provided to respondents and the basis for the
assurance in statute, regulation, or agency policy. If the collection requires a system of
records notice (SORN) or privacy impact assessment (PIA), those should be cited and
described here.
This collection has an approved privacy statement on applicable forms, and published SORN.
11. Provide additional justification for any questions of a sensitive nature.
The questions included on this form are consistent with OMB’s guidance for requesting a medical
exemption.
12. Provide estimates of the respondent burden hours and labor costs
Information
Collection
Instrument
Part 2

Table - Estimated Annualized Respondent Burden Hours
Annual # of
Total # of
Type of
# Of
Burden
Responses/
Annual
Respondent (e.g., Respondents
Hours/
Respondent
Responses
Occupational Title)
(a)
Response (d)
(b)
(c) = (a) x (b)
Medical Provider
4000
1
4000
2

Totals

Type of Respondent/
Occupational Title

4,000
Table - Estimated Annualized Respondent Labor Costs
Number of
Number of Responses Average Burden
Hourly
Respondents
per Respondent
per Response
Wage Rate*

Total Annual
Burden
Hours
(e) = (c) x (d)
8,000
8,000

Total Burden
Costs

Medical Provider

1000

1

10/60

$55.93

$9.32

Total

--

--

--

--

$9321

* https://www.bls.gov/bls/blswage.htm

13. Provide an estimate for the total annual cost burden to respondents or record keepers
resulting from the collection of information. (Do not include the cost of any burden costs
already reflected on the burden worksheet).
Annualized costs to respondents in addition to the labor burden costs addressed in Section 12 above
of this document to complete this collection. Postage @.58 x 4,000= $2,320.
14. Provide estimates of annualized cost to the Federal government.
Estimated Annualized Costs to the Federal Government is $247, 500 based on federal staff
personnel from GS-12 through GS-15.

15. Explain the reasons for any program changes or adjustments reported in ROCIS.
This is a new information collection.
16. For collections of information whose results will be published, outline plans for tabulation
and publication.
DOT will not publish the results of this information collection.
Also, the Department is required to report to OMB on the total number of employees who are fully
vaccinated, partially vaccinated, requesting reasonable accommodations, or not vaccinated.
17. If seeking approval to not display the expiration date for OMB approval of the information
collection, explain the reasons that display would be inappropriate.
The OMB Expiration Date will be displayed on the collection instrument.
18. Explain each exception to the certification statement identified in “Certification for
Paperwork Reduction Act Submissions."
The agency certifies compliance with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).