Forms related to Reasonable Accommodation for Personal Health and Religious Information

Forms and Documents

Document Name	Status
Form 1 Reasonable Accommodation Forms Form	New
20211123 Emergency Justification Letter - KDahl signed.pdf Supplementary Document	2021-11-29
Supporting Statement A RA Forms ICR.pdf Supporting Statement A	2021-11-29

IC Document Collections

IC ID	Document Title	Status
250571	Reasonable Accommodation Forms Form	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3045-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: CNCS	Agency Tracking No:
Title: Forms related to Reasonable Accommodation for Personal Health and Religious Information
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: 12/08/2021
Date Submitted to OIRA: 11/29/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	80	0
Time Burden (Hours)	140	0
Cost Burden (Dollars)	11,910	0

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Abstract: To meet the requirements of the Executive Orders and Task Force recommendations, AmeriCorps is seeking to create and maintain a Reasonable Accommodations system of records to allow for the collection and protection of information related to medical-based accommodation requests and accommodation requests made for sincerely held religious beliefs, practices, or observances. The forms associated with this system of records will facilitate the processing of requests for exemptions from the vaccine requirement.

Emergency Justfication: See attached memo.

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Authorizing Statute(s): US Code: 42 USC 12501 Name of Law: National Community Service Act et. seq.
  

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
Reasonable Accommodation Forms	1, 2, 3, 3	Reasonable Accommodation: Medical Exemption ,   Reasonable Accommodation: Medical ,   Reasonable Accommodation Form: Religious ,   Request Religious Exemption

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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	80	0	0	80	0	0
Annual Time Burden (Hours)	140	0	0	140	0	0
Annual Cost Burden (Dollars)	11,910	0	0	11,910	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: Net burden has increased because this is a new information collection.

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Annual Cost to Federal Government: $4,700

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: 11/29/2021

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