Request for a Medical
Exception to the COVID-19 Vaccination Requirement
New
collection (Request for a new OMB Control Number)
No
Emergency
11/10/2021
11/05/2021
Requested
Previously Approved
6 Months From Approved
35
0
6
0
0
0
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.
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.
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
EO: EO 14043 Name/Subject of EO: Requiring
Coronavirus Disease 2019 Vaccination for Federal Employees
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:
(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;
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.
Form Unknown Medical Certification for COVID-19 Vaccine Exception
Medical Exception Request-Letter-11_4_21.pdf
Medical Certification for COVID-19 Vaccine Exception