COVID Vax Disability Request Form

U.S. DEPARTMENT OF STATE
REQUEST FOR A MEDICAL EXCEPTION
TO THE COVID-19 VACCINATION REQUIREMENT
Pursuant to guidance and instructions from the Office of Management and Budget
(OMB), the information requested below will be used to determine if the requesting
employee is entitled to a disability accommodation related 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. In the course of adjudicating the request, the Department of State may 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 pursuant to standards for reasonable accommodation in the Rehabilitation Act of
1973 as amended, absent undue hardship to the Department. 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. Guidance
on medical considerations that may warrant a delay is available on the Safer Federal
Workforce website.
The Department of State will keep confidential any medical information provided, subject
to 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, up to and 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 GTM/OAA/DRAD through
the GTM Next Portal here: https://gtmprod.servicenowservices.com/next. Click on
“Service Catalog” to access “Reasonable Accommodations Request”. If you
cannot access the GTM Next Portal, e-mail [email protected]

Authority: The information is sought pursuant to Executive Order 14043, Requiring

Coronavirus Disease 2019 Vaccination for Federal Employees (Sept. 9, 2021); Executive
Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20,
2021); Executive Order 12196, Occupational Safety and Health Program for Federal

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Employees (Feb. 26, 1980); Executive Order 13163, Increasing the Opportunity for
Individuals With Disabilities To Be Employed in the Federal Government (July 26, 2000);
Executive Order 13164, Requiring Federal Agencies To Establish Procedures To
Facilitate the Provision of Reasonable Accommodation (July 26, 2000); and 5 U.S.C.
chapters 11, and 79, 22 U.S.C. 4084, and 42 U.S.C. 12112(d).

Purpose: This information is being collected and maintained to promote the safety of

Federal buildings and the Federal workforce consistent with the above-referenced
authorities, the COVID-19 Workplace Safety: Agency Model Safety Principles
established by the Safer Federal Workforce Task Force, and guidance from the Centers
for Disease Control and Prevention and the Occupational Safety and Health
Administration. The information solicited on this form will permit the Bureau of Global
Talent Management, Office of Accessibility & Accommodations, Disability Reasonable
Accommodations Division (GTM/OAA/DRAD) to engage the individual in order to
adjudicate requests for a reasonable accommodation related to the COVID-19
vaccination requirement.

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, where applicable, to a
Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the
work environment. Additionally, the information on this form may be shared with
consulting services that provide information about available aids, devices, and methods
of accommodating employees with disabilities; with the Department of Justice in
connection with proceedings before a court, adjudicative body, or other administrative
body, if the information is arguably relevant and necessary to the litigation; in response
to an order from a court or administrative body directing the production of such
information; and to disclose information to Equal Employment Opportunity (EEO)
counselors and EEO investigators in connection with EEO complaints and to the EEOC.
A complete list of the routine uses can be found in the applicable system of records
notices associated with the specific type of information, including State-31, Human
Resources Records, 78 Fed. Reg. 43258 (July 19, 2013); OPM/GOVT-10, Employee
Medical File System of Records, 75 Fed. Reg. 35099 (June 21, 2010), amended 80 Fed.
Reg. 74815 (Nov. 30, 2015); and State-24, Medical Records, 74 Fed. Reg. 24891 (May
26, 2009), amended 80 Fed. Reg. 7671 (Feb. 11, 2015). 

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Disclosure: Providing this information is voluntary. However, failure to submit this

form or provide the information requested on this form may impact a decision regarding
your reasonable accommodation request. All employees who do not submit appropriate
documentation confirming that they are fully vaccinated will be treated as not fully
vaccinated and will be required to comply with enhanced COVID-19 mitigation protocols,
including mask wearing, physical distancing, travel restrictions, and any testing protocol
required by the Department, even if they have requested or been approved for an
accommodation.

Part 1 – To Be Completed by the Employee
Employee Name (First, Last Name)

Date of Request (mm/dd/yyyy)

Supervisor’s Name

Employee Phone Number

Employee State e-mail

Employee Bureau

Employee Office

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 Employee Name

Date (mm/dd/yyyy)

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Part 2 – To be Completed by the Employee's Medical Provider
Employee Name (First & Last Name)

Medical Provider Name (First & Last Name)

Medical Provider Contact Phone Number

Medical Provider Address

Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The Department of State requires its employees to be fully vaccinated against COVID19 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 The Department of State in its reasonable
accommodation process. If you have questions about completing this form, please
contact the Disability and Reasonable Accommodation Division at [email protected].
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.

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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 is it expected to end or
expire (allowing for COVID-19 vaccination to begin after the date you provided):

Medical Provider Title

Medical Provider Signature

Date (mm/dd/yyyy)

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