Supporting Statement A RA Forms ICR

Supporting Statement
Corporation for National and Community Service (AmeriCorps)

Emergency Information Collection Submission for the new agency SORN:
CNCS-10-CEO-PHRI: PERSONAL HEALTH AND RELIGIOUS INFORMATION

Part A:
A.1

Justification

Circumstances That Make the Collection of Information Necessary

The collection of this information allows AmeriCorps to comply with Executive Order (EO)
13991, Protecting the Federal Workforce and Requiring Mask-Wearing, requiring that all
contractors working on an AmeriCorps campus attest to being vaccinated or follow alternative
safety measures; EO 14043, Executive Order on Requiring Coronavirus Disease 2019
Vaccination for Federal Employees, requiring Federal employees are vaccinated against
COVID-19 “subject to exceptions as required by law”; and EO 14042, Ensuring Adequate
COVID Safety Protocols for Federal Contractors, requiring Federal contractors and
subcontractors to be vaccinated against COVID-19 “subject to exceptions as required by law.”
The President’s Safer Federal Workforce Task Force (“Task Force”) has issued guidance to
Federal agencies, including AmeriCorps, relating to medical and religious accommodations, as
those are the two exceptions required by law. Employees may seek a legal exemption to the
vaccination requirement due to a disability, using the attached forms. The agency may also ask
for other information, as needed.
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.
A.2

How Information Will Be Used, by Whom, and for What Purpose

AmeriCorps’ Equal Employment Opportunity Program (EEOP) proposes to collect this
information to maintain personal health and religious information submitted as part of (1)
medical-based and religious-based reasonable accommodation requests; (2) public health
emergency or similar health and safety incidents, such as a pandemic, epidemic, or man-made
emergency; and/or (3) any other lawful collection of health-related information that is necessary
to ensure a safe and healthy environment for individuals who occupy AmeriCorps facilities,
attend AmeriCorps-sponsored events, participate in AmeriCorps programs, or are otherwise
engaged in official business on behalf of the agency. The system will assist the agency in the

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collection, storing, dissemination, and disposal of personal health and religious information
collected and maintained by the agency.
A.3

Use of Information Technology

Individuals will electronically submit attestation forms indicating their vaccine status. If they do
not have access to the online tool, paper forms may be provided. Individuals requesting an
exemption from the vaccine mandate submit a request via email and are then provided the
appropriate forms to sign and return to the EEOP for processing. The forms will be made
publicly available online and fillable for easy submission.
A.4

Efforts to Identify Duplication

There are no other sources of information by which AmeriCorps can meet the purposes described
in A2 (above).
A.5

Efforts to Minimize Burden on Small Businesses

There is no impact on small businesses.
A.6

Consequences of Not Conducting the Collection

In the absence of this collection, AmeriCorps will be unable to comply with the Executive
Orders. In addition, AmeriCorps will be unable to comply with the requirement set forth by the
Americans with Disabilities Act of 1990, as amended (42 U.S.C. §§ 12101 et seq.) that
reasonable accommodations be made available to those who qualify where there is no undue
burden to the agency. This collection is not recurring.
A.7

Special Circumstances Inconsistent with CFR Section 1320.5(d)(2)

There are no special circumstances associated with this data collection.
A.8

Federal Register Comments and Persons Consulted Outside the Agency

None. This is an emergency ICR with a request to approve without notice in the Federal
Register. A standard ICR will be submitted at a later date with notice.
A.9

Payments to Respondents

There will be no payments to respondents.
A.10

Assurance of Confidentiality

The agency will be required to keep confidential any medical information provided, subject to
the applicable Rehabilitation Act standards. The agency will be required to keep confidential all
information provided, including religious information and other personally identifiable
information, subject to applicable Privacy Act and National Institute of Standards and
Technology (NIST) guidance and has adopted appropriate administrative, technical, and physical
controls in accordance with its security program to protect the confidentiality, integrity, and
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availability of the information, and to ensure that records are not disclosed to or accessed by
unauthorized individuals. Moreover, AmeriCorps’ Office of Information Technology
(OIT)/Cybersecurity ensures Security and Privacy controls are in place, compliant with the
Federal Information Security Management Act of 2002, as amended (FISMA), and all FISMArelated requirements, to protect the confidentiality, integrity and availability of the information
collected, stored and/or processed.
A.11

Questions of a Sensitive Nature

These forms include questions regarding medical and religious information. This information is
being collected and maintained to document the need for a reasonable accommodation.
Furnishing the requested information is required to establish that the individual has a sincerely
held religious observance, practice, or belief, or a covered disability and the functional
limitations of the disability, and the need for reasonable accommodation. Failure to fully
complete the form or refusal to provide the requested documentation may lead to a breakdown in
the reasonable accommodation process and could result in a determination that the individual is
not entitled to reasonable accommodation.
A.12

Estimates of Respondent Burden

The agency typically receives few requests for accommodation in any given year. The new
vaccine requirement set out in E.O. 14043 has generated a handful of requests, though still a low
rate. These forms are typically filled out by the individual requesting the accommodation and in
the case of medical requests, their medical providers contribute. This response time includes one
hour for the individual to fill out the form and two hours for the medical practitioner to provide
input for medical requests. The religious based requests are therefore limited to one half hour
only.

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Estimated Annualized Burden Table
Collection
Instrument
Request for a
COVID-19 Medical
Exemption
Request for a
Medical
Accommodation
Request for a
COVID-19
Religious
Exemption
Request for a
Religious
Accommodation
TOTALS:

Number of
Frequency
Respondents of Response

Annual
hour
burden

Total
Burden
Hours

20

1

3

60

20

1

3

60

20

1

.5

10

20
80

1

.5
1.75

10
140

The agency may on rare occasions receive requests for accommodations from participants in
agency programs. These members and volunteers are not considered employees for the purposes
of PRA and as such are included in burden calculations. The hourly wage rate varies across
programs and regions, so the agency is applying the federal minimum wage as no members or
volunteers are paid above this rate. The hourly wage rate for medical providers is based on the
Hourly Mean Wage for Offices of Physicians as published by the U.S. Department of Labor,
Bureau of Labor Statistics, May 2020, found at https://www.bls.gov/oes/current/oes291228.htm .
Estimated Annualized Cost to Respondents

Type of
Respondents

Total Annual
Burden Hours

Hourly
Respondent
Wage Rate

Respondent
Cost

Individual Medical
Providers

80

$117.68

$9,414.40

Individual
members/volunteers
TOTALS:

60
140

$41.59
N/A

$2,495.40
$11.909.80

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A.13

Total Annual the Cost Burden to Respondents Excluding Hour Burden

Respondents incur no annualized capital/startup or ongoing operation and maintenance costs
associated with this collection. Cost burden to respondents consists solely of the time required to
complete the surveys and follow-up interviews as necessary.
A.14

Estimates of Annualized Government Costs

Cost
Federal
Oversight

Contractor Cost

Pay
Band

% of
Salary* Effort

NY-4
NY-3

145,000
90,000

0

Fringe if
applicable

2.00% N/A
2.00% N/A

0

0

Total
A.15

Total Cost to
Government
$2,900
$1,800

$0
$4,700

Changes in Reported Hour or Cost Burden

This is the first time this collection has been proposed, so there are no changes to the hour or cost
burden.
A.16 Timetable for Collection and Analysis
This information is not intended for publication.
A.17

Display of Expiration Date for OMB Approval

CNCS is not requesting a waiver for the display of the OMB approval number and expiration
date on the data collection instruments.
A.18

Exceptions to Certification Statement

This submission does not require an exception to the Certificate for Paperwork Reduction Act (5
CFR 1320.9).

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