Request for a Medical Exception to the COVID-19 Vaccination Requirement

Forms and Documents

Document Name	Status
Form FCC Form 5643 Federal Government Form and Instruction	New
Form FCC Form 5643 Business or other for-profit Form and Instruction	New
Form FCC Form 5643 Individuals or Households Form and Instruction	New
Emergency PRA Approval Cover Letter for Collecting Info for COVID Medical Exemption Form_10.-29-21 signed.pdf Supplementary Document	2021-11-01
Emergency PRA Supporting Statement for COVID Medical Exemption (final version).docx Supporting Statement A	2021-11-01

IC Document Collections

IC ID	Document Title	Status
249997	Federal Government Form and Instruction	New
249996	Business or other for-profit Form and Instruction	New
249992	Individuals or Households Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3060-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: FCC	Agency Tracking No: OWD
Title: Request for a Medical Exception to the COVID-19 Vaccination 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: 11/08/2021
Date Submitted to OIRA: 11/01/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	100	0
Time Burden (Hours)	50	0
Cost Burden (Dollars)	0	0

---

Abstract: Pursuant to Executive Order 14043, Federal employees must be fully vaccinated against COVID-19 by November 22, 2021. FCC employees may request reasonable accommodation from the vaccination requirement due to a documented medical necessity. Employees seeking consideration of such reasonable accommodation requests must provide a release form to permit the FCC to seek relevant information from their medical provider to support the employee's request. This process must be completed by November 22, 2021. This process will not be able to occur without the collection of information from employee physicians to scrutinize the legitimacy of such reasonable accommodation requests.

Emergency Justfication: The Federal Communications Commission (Commission or FCC) requests Office of Management and Budget (OMB) approval to submit the information collection described herein under the “emergency processing” provisions of the Paperwork Reduction Act (PRA) of 1995, 5 CFR 1320.13. The Commission is requesting clearance for a new information collection entitled [OMB Control Number 3060-XXXX], Request for a Medical Exception to the COVID-19 Vaccination Requirement, FCC Form 5643. For the reasons explained below, We respectfully request OMB approval for this new information collection at the earliest possible time. The information collection requirements to be reported under this new collection are the result of requirements imposed by an Executive Order issued by President Biden regarding mandatory COVID-19 vaccination among Federal employees. On September 9, 2021, President Biden issued Executive Order 14043 to protect the health and safety of the Federal workforce and to promote the efficiency of the civil service. Pursuant to the Executive Order and implementing guidance, the Federal Communications Commission (FCC) informed its workforce that, other than in limited circumstances where a reasonable accommodation is legally required, all employees need to be fully vaccinated against COVID-19 by November 22, 2021, regardless of where they are working.

---

Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
   US Code: 29 USC 791 Name of Law: The Rehabilitation Act of 1973, as amended
   EO: EO 13164 Name/Subject of EO: Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommo
   EO: EO 13164 Name/Subject of EO: Equal Employment Opportunity Commission’s Policy Guidance
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Business or other for-profit	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Federal Government	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Individuals or Households	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT

---

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	100	0	0	100	0	0
Annual Time Burden (Hours)	50	0	0	50	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: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection resulting in a program change/increase of 100 respondents, 100 responses, and 50 total estimated burden hours.

---

Annual Cost to Federal Government: $0

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

---

Common Form ICR:  No

---

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: 11/01/2021

---