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

Forms and Documents

Document Name	Status
Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	New
NTSB FORM Request for Medical Exception.pdf Supplementary Document	2021-11-01
NTSB Supporting Statement A for MEDICAL EXCEPTION REQUEST FORM.pdf Supporting Statement A	2021-11-01
NTSB EMERGENCY JUSTIFICATION LETTER for Medical Exception Request Form.pdf Supplementary Document	2021-11-01

IC Document Collections

IC ID	Document Title	Status
250005	Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3147-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: NTSB	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: 11/03/2021
Date Submitted to OIRA: 11/01/2021

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	20	0
Time Burden (Hours)	20	0
Cost Burden (Dollars)	1,012	0

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Abstract: To comply with the September 9, 2021, Executive Order (E.O.) 14043 (Requiring Coronavirus Disease 2019 Vaccination for Federal Employees) and October 2021 guidance from the Safer Federal Workforce Task Force, the NTSB created the following form: Request for a Medical Exception to the COVID-19 Vaccination Requirement. This form is a new collection for agency employees requesting a medical exception to the vaccine requirements. The agency will use this form to determine whether the employee provided sufficient information to justify the request.

Emergency Justfication: If the collection is not conducted or is conducted less frequently, the NTSB will be delayed in making determinations on requests from its employees for medical exceptions to the vaccine mandate to meet the requirements of the E.O. and Task Force recommendations.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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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

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination Requirement	N/A	Request for a Medical Exception to the COVID-19 Vaccination Requirement

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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	20	0	0	20	0	0
Annual Time Burden (Hours)	20	0	0	20	0	0
Annual Cost Burden (Dollars)	1,012	0	0	1,012	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: To comply with the September 9, 2021, Executive Order (E.O.) 14043 (Requiring Coronavirus Disease 2019 Vaccination for Federal Employees) and October 2021 guidance from the Safer Federal Workforce Task Force, the NTSB created the following form: Request for a Medical Exception to the COVID-19 Vaccination Requirement. This form is a new collection for agency employees requesting a medical exception to the vaccine requirements.

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Annual Cost to Federal Government: $1,278

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

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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: 11/01/2021

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