Form 1 Request for a Medical Exception to the COVID-19 Vaccinat

OMB Control No. ____________
Est. Avg. Burden per Response: 3 hours

REQUEST FOR A MEDICAL EXCEPTION 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. The agency may also 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 under applicable Rehabilitation Act
standards for reasonable accommodation absent undue hardship to the agency. 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. Safer Federal Workforce Task Force
guidance on medical considerations that may warrant a delay is available here. The agency will be
required to keep confidential any medical information provided, subject to the 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, 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 your agency’s designated point of
contact.

Privacy Act Statement: Pursuant to 5 U.S.C. § 552a(e)(3), the following Privacy Act Statement serves to
inform you about personally identifiable and medical information collected through this form. This
collection of information is authorized under section 501 of the Rehabilitation Act of 1973, 29 U.S.C. 791;
Executive Orders 13164, 13548, and 14043; and 29 C.F.R. pt. 1614. The collected information will be used
by the Commission to consider your request for a reasonable accommodation due to a disability under the
Rehabilitation Act. Failure to provide this information may result in denial of your request. The information
collected in this form may be disclosed in accordance with the routine uses specified in OSHRC-9 (available
at https://www.oshrc.gov/privacy), the Commission’s system-of-records notice that covers reasonable
accommodation records. These records will be retained in accordance with General Records Schedule 2.3,
Item 20.
Paperwork Reduction Act Notice: We have estimated that each response to this collection of information
by requesters will take 3 hours. Our estimate includes the time necessary to read the instructions, gather
the required data, complete Part 1 and review responses, provide the form to medical providers for
completion of Part 2, and retrieve the form for submission to the agency. If you have any questions or
comments on this estimate, or on how we can improve the collection and reduce the burden it causes you,
please contact the Review Commission at (202) 606-5100. You are not required to respond to a collection
of information sponsored by the Federal government, and the government may not conduct or sponsor this
collection, unless it displays a currently valid OMB control number. This collection has been assigned OMB
Control Number _______.

OMB Control No. ____________
Est. Avg. Burden per Response: 3 hours
Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Department

Division

Position

Supervisor

Phone Number

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 Name

Date

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The Occupational Safety and Health Review Commission requires its employees to be fully vaccinated
against COVID-19 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
Review Commission in its reasonable accommodation process. If you have questions about completing
this form, please contact the Review Commission's reasonable accommodation coordinator 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.
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 it is expected to end or expire (allowing
for COVID-19 vaccination to begin after the date you provided):

Medical Provider Name/Title
Medical Provider Signature

Date