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 FCC Form 5643 Federal Government	Form and Instruction	Modified	Repair queued
Form FCC Form 5643 Business or other for-profit	Form and Instruction	Modified	Repair queued
Form FCC Form 5643 Individuals or Households	Form and Instruction	Modified	Repair queued
3060-1295 Explanation of Non-Substantive Changes for Medical Exemption Form_12.6.21.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2021-12-06	Repair queued
Emergency PRA Approval Cover Letter for Collecting Info for COVID Medical Exemption Form_10.-29-21 signed.pdf	Supplementary Document	Uploaded 2021-11-01	Repair queued
Emergency PRA Supporting Statement for COVID Medical Exemption (final version).docx	Supporting Statement A	Uploaded 2021-11-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
249997	Federal Government	Form and Instruction	Modified
249996	Business or other for-profit	Form and Instruction	Modified
249992	Individuals or Households	Form and Instruction	Modified

ICR Details

OMB Control No: 3060-1295	ICR Reference No: 202112-3060-003
Status: Received in OIRA	Previous ICR Reference No: 202111-3060-001
Agency/Subagency: FCC	Agency Tracking No: OWD
Title: Request for a Medical Exception to the COVID-19 Vaccination Requirement
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 11/08/2021
Date Submitted to OIRA: 12/07/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	05/31/2022	05/31/2022
Responses	100	100
Time Burden (Hours)	50	50
Cost Burden (Dollars)	0	0

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Abstract: This submission is being made for proposed non-substantive changes to an existing information collection pursuant to 44 U.S.C. § 3507. This submission seeks to modify FCC Form 5643 to correct a non-substantive typographical error. The Form Number was corrected to read “FCC-5643” instead of the erroneous “FCC-5634.” There are no changes in the burdens and no costs are associated with this information collection. Pursuant to Executive Order 14043, Federal employees must be fully vaccinated against COVID-19 by November 22, 2021. FCC employees may request reasonable accommodation from the vaccination requirement due to a documented medical necessity. Employees seeking consideration of such reasonable accommodation requests must provide a release form to permit the FCC to seek relevant information from their medical provider to support the employee's request. This process must be completed by November 22, 2021. This process will not be able to occur without the collection of information from employee physicians to scrutinize the legitimacy of such reasonable accommodation requests.

Emergency Justfication: The Federal Communications Commission (Commission or FCC) requests Office of Management and Budget (OMB) approval to submit the information collection described herein under the “emergency processing” provisions of the Paperwork Reduction Act (PRA) of 1995, 5 CFR 1320.13. The Commission is requesting clearance for a new information collection entitled [OMB Control Number 3060-XXXX], Request for a Medical Exception to the COVID-19 Vaccination Requirement, FCC Form 5643. For the reasons explained below, We respectfully request OMB approval for this new information collection at the earliest possible time. The information collection requirements to be reported under this new collection are the result of requirements imposed by an Executive Order issued by President Biden regarding mandatory COVID-19 vaccination among Federal employees. On September 9, 2021, President Biden issued Executive Order 14043 to protect the health and safety of the Federal workforce and to promote the efficiency of the civil service. Pursuant to the Executive Order and implementing guidance, the Federal Communications Commission (FCC) informed its workforce that, other than in limited circumstances where a reasonable accommodation is legally required, all employees need to be fully vaccinated against COVID-19 by November 22, 2021, regardless of where they are working.

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
   US Code: 29 USC 791 Name of Law: The Rehabilitation Act of 1973, as amended
   EO: EO 13164 Name/Subject of EO: Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommo
   EO: EO 13164 Name/Subject of EO: Equal Employment Opportunity Commission’s Policy Guidance
  

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: 3

table that charts list of burden

IC Title	Form No.	Form Name
Business or other for-profit	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Federal Government	FCC Form 5643	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Individuals or Households	FCC Form 5643	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	100	0	0	0	0
Annual Time Burden (Hours)	50	50	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

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: 12/07/2021

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