COVID-19 Vaccination Requests for Waiver

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Religious Accomodation Request Form	Form and Instruction	New	Available
COVID Vax Disability Request Form	Form and Instruction	New	Available
Notional Supporting Statement for Emergency Req - COVID Vacc Requests for Waiver FINAL.docx	Supporting Statement A	Uploaded 2021-12-15	Available
Emergency PRA Letter - Signed.pdf	Supplementary Document	Uploaded 2021-12-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250799	REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction	New	Religious Accomodation Request Form
250798	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	Form and Instruction	New	COVID Vax Disability Request Form

ICR Details

OMB Control No: 1405-0246	ICR Reference No: 202112-1405-009
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: COVID-19 Vaccination Requests for Waiver
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: 12/17/2021
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/15/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/15/2021
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2022	6 Months From Approved
Responses	100	0	0
Time Burden (Hours)	1	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: Per guidance from the Safer Federal Workforce Task Force, an agency may be required to provide a reasonable accommodation to employees or prospective employees who communicate to the agency that they are not vaccinated against COVID-19 because of a medical reason or disability, or because of a sincerely held religious belief, practice, or observance.

Emergency Justfication: State has determined that this information must be collected prior to the time periods established under Part 1320 of the regulations and that this information is essential to implement the Department’s health and safety measures included within recent Centers for Disease Control and Prevention and Safer Federal Workforce Task Force Guidance. Government agencies have an urgent need to require vaccinations from prospective employees per Executive Order 14043; at the same time, some of those employees have a legal right to claim a religious or medical exception from this vaccination requirement.

---

Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	NA	COVID Vax Disability Request Form
REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT	NA	Religious Accomodation Request Form

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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)	1	0	0	1	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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: New collection - see Supporting Statement.

---

Annual Cost to Federal Government: $6,260

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.     No

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

---

Common Form ICR:  No

---

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: 12/15/2021

---