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

ICR 202112-3202-001

OMB: 3202-0005

Federal Form Document

Forms and Documents
ICR Details
Received in OIRA
Request for a Medical Exception to the COVID-19 Vaccination Requirement
New collection (Request for a new OMB Control Number)   No
Emergency 01/13/2022
  Requested Previously Approved
6 Months From Approved
3 0
9 0
0 0

The collection of information is necessary for the Review Commission to consider any employee request for a medical exception to the COVID-19 vaccination requirement. The information is collected from the requester's medical provider. Only agency employees are covered by the form. This is a new collection of information. The information collected will be used to determine whether an employee is entitled under section 501 of the Rehabilitation Act of 1973, 29 U.S.C. 791, to a medical exception to the vaccine mandate for federal employees set forth in E.O. 14043.
Emergency clearance of our agency's medical exception form is necessary to allow our agency to timely process any medical exception requests to the COVID-19 vaccination requirement. This is essential to our agency's mission, in that disruption to the work of any employee requesting an exception would, in tum, undermine the agency's ability to meet our mission and function at an optimal level.

EO: EO 14043 Name/Subject of EO: EO on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (9/9/2021)
   US Code: 29 USC 791 Name of Law: Rehabilitation Act of 1973

Not associated with rulemaking


  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 3 0 0 3 0 0
Annual Time Burden (Hours) 9 0 0 9 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
There has been no change in burden.

Ronald Bailey 202 606-5410 ext. 259 [email protected]


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:
    (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;
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.

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