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 1 Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form	New	Repair queued
11-08-21_LTR_Medical Exceptions_21-01789_U_Initial.pdf	Supporting Statement B	Uploaded 2021-11-15	Repair queued
ATTACH 2 (Support Statement A)_U.pdf	Supporting Statement A	Uploaded 2021-11-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250346	Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202111-3440-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: ODNI	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: 11/16/2021
Date Submitted to OIRA: 11/15/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	100	0
Time Burden (Hours)	125	0
Cost Burden (Dollars)	5,176	0

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Abstract: Pursuant to Office of Management and Budget (OMB) procedures established at 5 C.F.R. Part 1320, Controlling Paperwork Burdens on the Public, I request that the proposed Office of the Director of National Intelligence (ODNI) information collection covered by the ODNI form titled, "Request for a Medical Exception to the COVID-19 Vaccination Requirement," (enclosed) be processed as an emergency clearance request in accordance with 5 C.F.R. § 1320.13, Emergency Processing.

Emergency Justfication: This information must be collected prior to the time periods established under Part 1320 of the regulations and that this information collection is essential to implement health and safety measures requiring all civilian Federal employees be vaccinated as mandated by Executive Order 14043 of 09 September 2021, Requiring Corona virus Disease 2019 Vaccination for Federal Employees, and included within Safer Federal Workforce Task Force Guidance which mandated all Federal employees be vaccinated by 22 November 2021.

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Authorizing Statute(s): EO: EO 13994 Name/Subject of EO: Ensuring a Data-Driven Response to COVID-19 and Future High-Consequence Public Health Threats (J
   EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing (January 20, 2021);
  

Citations for New Statutory Requirements: EO: EO 13991 Name/Subject of EO: Protecting the Federal Workforce and Requiring Mask-Wearing (January 20, 2021);

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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
Request for a Medical Exception to the COVID-19 Vaccination Requirement	1	Request for a Medical Exception to the COVID-19 Vaccination Requirement

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ICR Summary of Burden

table that charts list 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	100	0	0	100	0	0
Annual Time Burden (Hours)	125	0	0	125	0	0
Annual Cost Burden (Dollars)	5,176	0	0	5,176	0	0

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

Burden Increase Due to: Changing Regulations

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

Burden Reduction Due to:

Short Statement: New requirements in connection with COVID 19 response activities drives the change.

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Annual Cost to Federal Government: $4,655

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: 11/15/2021

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