Request for Medical exemption to COVID-19

OMB CONTROL NUMBER: 2105-XXXX
EXPIRATION DATE: mm/dd/yyyy

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 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 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 your agency’s designated point of
contact.
Privacy Act Statement
Authority: The Rehabilitation Act of 1973, as amended, 29 U.S.C. § 791; Executive Order 14043, Requiring
Coronavirus Disease 2019 Vaccination for Federal Employees (September 9, 2021); Executive Order 13164,
Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation,
65 Fed. Reg. 46,563 (Jul 28, 2000); and Equal Employment Opportunity Commission’s Policy Guidance on
Executive Order 13164: Establishing Procedures to Facilitate the Provision of Reasonable Accommodation,
Directives Transmittal Number 915.003 (October 20, 2000).
Purpose: The principal purpose for collecting this information is to permit the U.S. Department of
Transportation (DOT) and its components to assess whether individuals are entitled to a medical exemption
from the mandator Covid-19 vaccine requirement as a reasonable accommodation. Additionally, this
information is being collected and maintained by the DOT to record and track requests for such medical
exemptions, and their disposition.
Information collected in connection with a request for reasonable accommodation is confidential and may be
shared with DOT officials or DOT contractors only when those other individuals need to know the information
to make determinations on a reasonable accommodation request or to assist the Departmental Office of Civil
Right or the Office of Human Resources in making such a determination.
Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for the
system found in the System of Records Notice DOT/ALL 028—Employee Accommodations Files, 86 FR 64597
(November 18, 2021).

Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this information,
DOT may not be able to provide you with a medical accommodation to the Covid-19 vaccination requirement.

Paperwork Reduction Act Public Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be
subject to a penalty for failure to comply with a collection of information subject to the requirements of the
Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number.
The OMB Control Number for this information collection is 2105-XXXX. Public reporting for this collection of
information is estimated to be approximately 2 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, completing and reviewing the
collection of information.
All responses to this collection of information are mandatory. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, Office of Civil Rights, OST-32, Department of Transportation, 1200 New Jersey
Avenue, Washington, DC 20590.

Part 1 – To Be Completed by the Employee
[Agencies should modify these fields as needed for purposes of identifying the employee.]
Employee Name
Date of Request

Department
Position

Division
Supervisor

Phone Number

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 U.S. Department of Transportation (USDOT) 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 the USDOT in its
reasonable accommodation process.
If you have questions about completing this form, please contact
[email protected]
Please provide at least the following information, where applicable:

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; and
3. Any other medical condition that would limit the employee from receiving any COVID-19 vaccine.
Description of the medical condition for which the employee listed above should be
excepted from complying with a COVID-19 vaccination requirement:

The condition described above is:

temporary

long-term

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):

Medical Provider Name/Title

Medical Provider Signature

Date