Form NSF Medical Reasonable Accommodation Request

NATIONAL SCIENCE FOUNDATION (NSF)
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Pursuant to Government-wide and NSF policy, all NSF employees, as defined in 5 U.S.C. § 2105, and other
NSF staff (e.g., IPAs, fellows, student volunteers) are required to be vaccinated against COVID-19, with
exceptions only as required by law. NSF employees and other NSF staff may seek a legal exception to the
vaccination requirement due to a disability, using the form below. The agency may also ask for other
information, as needed. Requests for “medical accommodation” or “medical exceptions” will be treated as
requests for a disability accommodation and evaluated and decided under applicable Rehabilitation Act
standards for reasonable accommodation absent undue hardship to the agency. An individual 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. The agency will be required to keep
confidential any medical information provided, subject to the applicable Rehabilitation Act standards.
Individuals who receive an exception or a delay from the vaccination requirement would instead comply with
alternative health and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best of
your knowledge and ability. Any intentional misrepresentation to the Federal Government may result in
legal consequences, including termination and removal from service.
To request a medical exception or delay from the COVID-19 vaccination requirement using this form:

1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, you must submit the form to NSF’s designated point of contact
for reasonable accommodations (i.e., the Disability Program Manager in the NSF Office of
Diversity and Inclusion (ODI), [email protected]).

PRIVACY ACT STATEMENT
Authority: 5 U.S.C. 7902(d); Occupational Safety & Health Act (OSHA) of 1970, 29 U.S.C. 668(a); National Science Foundation Act of 1950,
Pub. L. 507-81; 29 CFR part 1904; 29 CFR 1910.1020 and 1960.66; Executive Orders 12196, 13991, and 14043; OMB Memoranda M-21-15
and M-21-25; Safer Federal Workforce Task Force, COVID-19 Workplace Safety: Agency Model Safety Principles; and other authorities,
including title VII of the Civil Rights Act of 1974, the Rehabilitation Act, and Equal Employment Opportunity Commission (EEOC) regulations,
as applicable. While this form is voluntary, failure to complete it may result in denial of an exemption from vaccination or testing
requirements and disciplinary or other action for non-compliance with such requirements, including termination and removal from service.
Purpose: NSF will use the information you provide to determine your eligibility for a reasonable accommodation for a disability, to include a
legal exception to the vaccination requirement. This information is being collected to assist NSF with maintaining a safe and healthy
workplace, including to protect individuals in NSF facilities and events from risks associated with a public health emergency; to plan and
respond to workplace and personnel flexibilities needed during such an emergency; to facilitate NSF's cooperation with public health
authorities; to perform contact tracing investigations and provide exposure notifications to NSF staff or other individuals; and to comply
with legal recordkeeping and reporting requirements.
Routine Uses: In addition to authorized internal NSF use, the information you provide may be disclosed to contractors, other Federal, State,
local and other agencies, health departments, medical authorities, and other entities in connection with health screening, contact tracing,
statistical reporting, and other efforts to address the spread of communicable diseases and/or a public health emergency. For a full list of
routine uses, see NSF-78 (NSF Staff & Visitor Medical Information), posted at https://www.nsf.gov/privacy/. If you use the services of the
NSF Health Unit or other NSF health programs, and this information is maintained as part of those health and medical records, additional
routine uses apply to those records. See NSF-79 (NSF Health Program Records), posted at https://www.nsf.gov/privacy/. See also OPM/
GOVT-10 (Employee Medical Files System Records), 75 FR 35099 (June 21, 2010), amended at 80 FR 74815 (Nov. 30, 2015).

Part 1 – To Be Completed by You (Requesting Individual)
Name

Date of Request

Directorate or Department

Division

Position

Supervisor

Phone Number

Medical or Disability Exception Request
I am requesting a medical exception to the requirement for COVID-19 vaccination or a delay because
of a temporary condition or medical circumstance. I declare that the information I have provided is
true and correct to the best of my knowledge and ability.

Your Signature
Print Name

Date

Part 2 – To be Completed by Your Medical Provider
Name (Requesting Individual)
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The National Science Foundation (NSF) requires its employees and other NSF staff to be fully vaccinated
against COVID-19 pursuant to Executive Order 14043, issued by the President of the United States, and
other applicable law, agreement or policy. The individual named above is seeking a medical exception to
the requirement for COVID-19 vaccination or a delay because of a temporary condition or medical
circumstance. Please complete this form to assist NSF in its reasonable accommodation process. If you
have questions about completing this form, please contact NSF's Disability Program Manager, who
serves as the agency's reasonable accommodation coordinator, by e-mail at [email protected], or by
phone at (703) 292-8020. Please provide at least the following information, where applicable.

1. The applicable contraindication or precaution for COVID-19 vaccination, and for each

contraindication or precaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether it is listed in the package insert or Emergency Use Authorization fact
sheet for each of the COVID-19 vaccines authorized or approved for use in the United States;
2. A statement that the individual’s condition and medical circumstances relating to the individual
are such that COVID-19 vaccination is not considered safe, indicating the specific nature of the
medical condition or circumstances that contraindicate immunization with a COVID-19 vaccine
or might increase the risk for a serious adverse reaction; and
3. Any other medical condition that would limit the individual from receiving any COVID-19
vaccine.

Description of the medical condition for which the individual listed above should be excepted from
complying with a COVID-19 vaccination requirement (attach/submit additional sheets, if needed):

The condition described above is:

temporary

long-term

If this is a temporary condition or medical circumstance, when it is expected to end or expire (allowing
for COVID-19 vaccination to begin after the date you provided):

Medical Provider Name/Title
Medical Provider Signature

Date

PAPERWORK REDUCTION ACT STATEMENT: A federal agency may not conduct or sponsor a collection of
information unless it displays a currently valid OMB control number, which is XXXX-XXXX for this form. We
estimate that completing the form, including the time to review instructions, should take medical providers no
more than two (2) hours to complete, and one (1) hour for the requesting individual (NSF employee or other
staff).