Medical Exemption Delay to Covid-19 Requirement

Forms and Documents

Document Name	Status
Form HUD-1001 Request for a Medical Exception to the COVID-19 Vaccination Form and Instruction	New
PRA Emergency Review Request Letter.pdf Supplementary Document	2021-11-19
PRA Supporting Statement--ej draft Medical Exception Only -Employees-11.16.2021.docx Supporting Statement A	2021-11-19

IC Document Collections

IC ID	Document Title	Status
250439	Request for a Medical Exception to the COVID-19 Vaccination Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-2501-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HUD/HUDSEC	Agency Tracking No:
Title: Medical Exemption Delay to Covid-19 Requirement
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: 11/22/2021
Date Submitted to OIRA: 11/19/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	200	0
Time Burden (Hours)	300	0
Cost Burden (Dollars)	0	0

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Abstract: Consistent with Executive Order 14043 on September 9, 2021, requiring federal employees to be vaccinated against COVID-19 in order to ensure the health and safety of federal workers and efficiency of the civil service. Requests for an exception to the COVID vaccination requirement will be documented on Form HUD-1001 Request to Medical Exception to the COVID-19 Requirement.

Emergency Justfication: Executive Order 14043 on September 9, 2021, requiring federal employees to be vaccinated against COVID-19 in order to ensure the health and safety of federal workers and efficiency of the civil service. Requests for an exception to the COVID vaccination requirement will be documented on Form HUD-1001 Request to Medical Exception to the COVID-19 Requirement.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination	HUD-1001	Request for a Medical Exception to the COVID-19 Vaccination Requirement

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ICR Summary 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	200	0	0	200	0	0
Annual Time Burden (Hours)	300	0	0	300	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: new collection

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Annual Cost to Federal Government: $14,904

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? Yes

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Common Form ICR:  No

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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: 11/19/2021

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