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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Not Applicable Privacy Act Statement for Medical Exception Form to COVID-19 Vaccination Requirement	Form	New	Available
Form Unknown Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction	New	Repair queued
Form Unknown Medical Certification for COVID-19 Vaccine Exception	Form and Instruction	New	Repair queued
Medical Exception Request-Letter-11_4_21.pdf	Supplementary Document	Uploaded 2021-11-05	Repair queued
Medical Exception to COVID Vaccination-Supporting Statement-11-4-2021.pdf	Supporting Statement A	Uploaded 2021-11-04	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250134	Medical Certification for COVID-19 Vaccine Exception	Form	New	Privacy Act Statement for Medical Exception Form to COVID-19 Vaccination Requirement
250134	Medical Certification for COVID-19 Vaccine Exception	Form and Instruction	New	Request for a Medical Exception to the COVID-19 Vaccination Requirement
250134	Medical Certification for COVID-19 Vaccine Exception	Form and Instruction	New

ICR Details

OMB Control No: 3084-0170	ICR Reference No: 202111-3084-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: FTC	Agency Tracking No:
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: 11/10/2021
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/17/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/05/2021
Terms of Clearance: This collection is approved for 6 months only. Should FTC want to use this collection for more than 6 months, the agency must publish a 60 and 30 day notice.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	6 Months From Approved
Responses	35	0	0
Time Burden (Hours)	6	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: On September 9, 2021, President Biden issued Executive Order 14,043, which 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. Employees may seek a legal exception to the vaccination requirement due to a disability, using the template form provided by the Safer Federal Workforce Task Force. Part one of the form, which is not subject to clearance under the Paperwork Reduction Act (“PRA”), provides that the individual employee would seek a medical exception to the requirement for COVID-19 vaccination or a delay because of a temporary condition or medical circumstance. Part two of the form, which is to be completed by the employee’s medical provider, is subject to clearance approval from the Office of Management and Budget under the PRA. The FTC needs information requested on part two of the form from the medical provider to effectively evaluate the employee’s reasonable accommodation request.

Emergency Justfication: Special circumstances exist that require an emergency clearance pursuant to 5 CFR 1320.13(a), therefore no notice has been published in the Federal Register. Executive Order 14,043 directed the Safer Federal Workforce Task Force to issue guidance within 7 days of the date of that order (Sept. 9, 2021) on implementation by federal agencies covered by the order. The Task Force thereafter directed that Federal employees must be fully vaccinated by November 22, 2021, other than in limited circumstances where the law requires an exception. Thus, the collection of information is needed prior to the expiration of time periods ordinarily required by the PRA statute and implementing rules and is essential to the mission of the FTC. 5 CFR 1320.13(a)(1)(i)-(ii). Additionally, public harm is reasonably likely to result if normal clearance procedures are followed. 5 CFR 1320.13(a)(2)(i). 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.

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Authorizing Statute(s): EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing
   EO: EO 12196 Name/Subject of EO: Occupational Safety and Health Program for Federal Employees
   US Code: 5 USC chapters 11 and 79
   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

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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

table that charts list of burden

IC Title	Form No.	Form Name
Medical Certification for COVID-19 Vaccine Exception	Not Applicable, Unknown	Request for a Medical Exception to the COVID-19 Vaccination Requirement ,   Privacy Act Statement for Medical Exception Form to COVID-19 Vaccination Requirement

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	35	0	35	0	0	0
Annual Time Burden (Hours)	6	0	6	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government:

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? No

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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: 11/05/2021

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