Medical Exception Request to the COVID-19 Vaccination Requirement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FMSHRC-09-001 Medical Exception Request to the Vaccination Requirement	Form and Instruction	New	Repair queued
2021-11-22 FMSRHC Transmittal Letter to OIRA .docx	Supplementary Document	Uploaded 2021-11-22	Repair queued
PRA Statement Part A.docx	Supporting Statement A	Uploaded 2021-11-22	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250454	Medical Exception Request to the Vaccination Requirement	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3079-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: FMSHRC	Agency Tracking No:
Title: Medical Exception Request 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: 12/03/2021
Date Submitted to OIRA: 11/22/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	6	0
Time Burden (Hours)	24	0
Cost Burden (Dollars)	0	0

---

Abstract: In order to ensure the health and safety of the Federal workforce and the efficiency of the civil service, full Coronavirus Disease 2019 Vaccination is now mandatory for all Federal employees, with exceptions only required by law, under the new Executive Order 14043. Employees may seek a legal exception to the vaccination requirement due to a disability or medical reason. Requests for “medical accommodation” or “medical exceptions” will be treated as requests for 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 exception under the Rehabilitation Act. Safer Federal Workforce Task Force guidance on medical considerations that may warrant a delay is available here.

Emergency Justfication: In accordance with government-wide policy that requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated against COVID-19, with exceptions only as required by law. Our agency is currently conducting the requisite steps so our employees may seek a legal exception to the vaccination requirement due to a disability. Requests for “medical accommodation” or “medical exceptions” will be treated as requests for disability accommodation and evaluated and decided under applicable Rehabilitation Act standards for reasonable accommodation absent undue hardship to the agency. Before we are able to circulate request forms to requestors, the Safer Federal Workforce Task Force has directed us to seek emergency review from OIRA.

---

Authorizing Statute(s): US Code: 29 USC 791 Name of Law: Rehabilitation Act Section 501
   EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  

Citations for New Statutory Requirements: EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees

---

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

---

Federal Register Notices & Comments
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 66301	11/22/2021
Did the Agency receive public comments on this ICR? No

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Medical Exception Request to the Vaccination Requirement	FMSHRC-09-001	Medical Exception Request to the Vaccination Requirement

---

ICR Summary of Burden

table that charts list 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	6	0	0	6	0	0
Annual Time Burden (Hours)	24	0	0	24	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: The increase in burden occurred due to a new federal mandate requiring all federal employees to be vaccinated for COVID-19. There is a minimal increase in burden for federal employees that will utilize the form to request a reasonable accommodation to the COVID-19 vaccination. We have been informed that 5-6 employees intend to request a medical exception. There is minimal increase in burden to the one staff member who will be processing, documenting and storing those requests. The largest burden was on the staff who had to interpret the new federal mandate, create the collection form, draft a Reasonable Accommodation SORN, and comply with the Privacy Act and Paperwork Reduction Act.

---

Annual Cost to Federal Government: $999

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: 11/22/2021

---