Form OGE Form 319 OGE Form 319 OGE Request for a Medical Exception to the Covid-19 Vacc

REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Government-wide policy 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 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 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. The agency will be
required to keep confidential any medical information provided, subject to the applicable Rehabilitation
Act standards. Employees 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 or removal from Federal 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 your agency’s designated POC.

Public Burden Information
This collection of information is estimated to take an average of ten minutes per response. Send comments regarding the
burden estimate or any other aspect of this collection of information to the Program Counsel, U.S. Office of Government
Ethics, Suite 500, 1201 New York Avenue, NW, Washington, DC 20005-3917. This form must display a valid OMB control
number, which is located on the bottom of the last page.

Privacy Act Statement
Authority: We are authorized to collect the information requested on this form pursuant to Executive Order 14043, Requiring
Coronavirus Disease 2019 Vaccination for Federal Employees (Sept. 9, 2021); 29 U.S.C. 791, Employment of Individuals with
Disabilities; 42 U.S.C. Chapter 126, Equal Opportunity for Individuals with Disabilities; 29 CFR Part 1630, Regulations to
Implement the Equal Employment Provisions of the Americans with Disabilities Act; Executive Order 12196, Occupational
Safety and Health Program for Federal Employees (Feb. 26, 1980); and 5 U.S.C. chapters 11 and 79.
Purpose: To document the consideration, decision, and implementation of requests for reasonable accommodation from the
COVID vaccination requirement set forth in Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for
Federal Employees (Sept. 9, 2021).
Routine Uses: While the information requested on this form is intended to be used primarily for internal purposes, in certain
circumstances it may be necessary to disclose this information externally, for example to disclose information to contractors,
grantees, or volunteers as necessary to perform their duties for the Federal Government, or to officials of the Office of
Special Counsel, Office of Personnel Management, Federal Labor Relations Authority, Merit Systems Protection Board, or the
Equal Employment Opportunity Commission when requested in the performance of their authorized duties. A complete list
of the routine uses can be found in the system of records notice associated with this collection of information, OGE/
INTERNAL-1, Pay, Leave, Travel, and Reasonable Accommodation Records, 86 Fed. Reg. 62537 (November 10, 2010).
Consequence of Failure to Provide Information: Providing this information is voluntary. Failure to provide this information
may delay or impede the processing of this reasonable accommodation request. Moreover, without an approved reasonable
accommodation request, failure to provide proof of COVID vaccination may result in disciplinary measures, up to and
including removal from Federal service, based on the requirements of Executive Order 14043, Requiring Coronavirus Disease
2019 Vaccination for Federal Employees (Sept. 9, 2021).

Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Agency

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.

Employee Signature
Print Name

Date

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The U.S. Office of Government Ethics (OGE) requires its employees to be fully vaccinated against
COVID-19 pursuant to Executive Order of the President of the United States. 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
OGE in evaluating this request. If you have questions about completing this form, please contact
Dale Christopher, OGE's Deputy Director for Compliance at [email protected] or 202-271-3215.
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 employee from receiving any COVID-19
vaccine.
Description of the medical condition for which the employee listed above should be
excepted from complying with a COVID-19 vaccination requirement:

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

OMB Control Number 3209-xxxx
Expires May 31, 2022

Date