Form 1 Reasonable Accommodation: Medical Exemption

REQUEST FOR A MEDICAL EXEMPTION TO THE
COVID-19 VACCINATION REQUIREMENT
The purpose of this form is to determine whether you may be eligible for a medical exemption to the
government-wide policy that requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated
against COVID-19. An exemption is provided only as required by law. Employees may seek a legal exemption 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 exemptions 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 exemption under the
Rehabilitation Act. Safer Federal Workforce Task Force guidance on medical considerations that may warrant a
delay is available here. The agency is required to keep confidential any medical information provided, subject to
the applicable Rehabilitation Act standards. Employees who receive an exemption 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 exemption or delay from the COVID-19 vaccination requirement:
1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. If more space is needed, please attach documents as necessary.
4. When both are completed, you must submit the form to the Disability Program Manager at
[email protected].

Privacy Act Statement
Authority:
We are authorized to collect the information requested on this form pursuant to Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021); Executive Order 14043,
Executive Order on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sep. 9, 2021);
Executive Order 12196, Occupational Safety and Health Program for Federal Employees (Feb. 26, 1980); and 5
U.S.C. chapters 11 and 79.
Purpose:
This information is being collected and maintained to promote the safety of Federal buildings and the Federal
workforce consistent with the above-referenced authorities, the COVID-19 Workplace Safety: Agency Model
Safety Principles established by the Safer Federal Workforce Task Force, and guidance from Centers for Disease
Control and Prevention and the Occupational Safety and Health Administration.
Routine Uses:
The information requested on this form is intended to be used primarily for internal purposes. However, in
certain circumstances it may be necessary to disclose this information externally. Examples include: to disclose
250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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information to a Federal, state, or local agency to the extent necessary to comply with laws governing reporting
of communicable disease or other laws concerning health and safety in the work environment; to adjudicative
bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the extent necessary to
carry out their authorized duties regarding Federal employment; to contractors, grantees, or volunteers as
necessary to perform their duties for the Federal Government; to other agencies, courts, and persons as necessary
and relevant in the course of litigation, and as necessary and in accordance with requirements for law
enforcement; or to a person authorized to act on your behalf. A complete list of the routine uses can be found in
the system of records notice associated with this collection of information, CNCS-10-CEO-PHRI, Personal
Health and Religious Information (86 FR 6458).
Part 1 – To Be Completed by the Person Requesting Exemption
Person Requesting Exemption

Date of Request

Office / Program

Work / Volunteer Location

Position

Supervisor

Phone Number and Email Address

Medical or Disability Exemption Request
I am requesting a medical exemption 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

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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Part 2 – To be Completed by the Person Requesting Exemption Medical Provider
Patient’s Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
AmeriCorps 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 exemption to the requirement for
COVID-19 vaccination or a delay because of a temporary condition or medical circumstance. Please complete this
form to assist AmeriCorps in its reasonable accommodation process. If you have questions about completing this
form, please contact Lisa Gray, AmeriCorps’ reasonable accommodation coordinator, at [email protected] or 202606-3221.
In the section below, 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
3. Any other medical condition that would limit the employee from receiving any COVID- 19 vaccine.
Please describe the medical condition for which the person listed above should be exempted
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 is it 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

250 E Street SW
Washington, D.C. 20525
202-606-5000 / 800-942-2677

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