COVID-19 Vaccine Supplemental Medical Provider Statement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement	Form	Modified	Repair queued
0651-0087 Supporting Statement 2022.docx	Supporting Statement A	Uploaded 2022-05-31	Repair queued
E.O. 14043 COVID 20210914.pdf	Supplementary Document	Uploaded 2022-05-31	Repair queued
Information Quality Guidelines _ USPTO.pdf	Supplementary Document	Uploaded 2022-05-31	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250233	COVID-19 Vaccine Supplemental Medical Provider Statement	Form	Modified

ICR Details

OMB Control No: 0651-0087	ICR Reference No: 202201-0651-001
Status: Received in OIRA	Previous ICR Reference No: 202111-0651-001
Agency/Subagency: DOC/PTO	Agency Tracking No:
Title: COVID-19 Vaccine Supplemental Medical Provider Statement
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/31/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2022
Responses	150	150
Time Burden (Hours)	25	25
Cost Burden (Dollars)	0	0

---

Abstract: Consistent with guidance from the Centers for Disease Control and Prevention (CDC), guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991 of January 20, 2021, Protecting the Federal Workforce and Requiring Mask-Wearing, and Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, the request for this collection of information is essential to implement the USPTO’s health and safety measures regarding the Federal employee medical exemptions to the COVID-19 mandatory vaccinations. The Rehabilitation Act of 1973, as amended, requires Federal agencies to provide reasonable accommodations to qualified employees with disabilities unless that reasonable accommodation would impose an undue hardship on the employee’s agency. See 29 U.S.C. 791; 29 CFR Part 1614; see also 20 CFR Part 1630 and Executive Order 13164 of July 26, 2000, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation. Section 2 of E.O. 14043 mandates that each agency “implement, to the extent consistent with applicable law, a program to require COVID-19 vaccination for all of its Federal employees, with exceptions only as required by law.” This COVID-19 Vaccine Supplemental Medical Provider Statement is necessary for USPTO to determine legal exemptions to the vaccine requirement under the Rehabilitation Act.

---

Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirius 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
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 16719	03/24/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 32382	05/31/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
COVID-19 Vaccine Supplemental Medical Provider Statement	USPTO-OEEOD 303	COVID-19 Vaccine Supplemental Medical Provider Statement

---

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	150	150	0	0	0	0
Annual Time Burden (Hours)	25	25	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:

---

Annual Cost to Federal Government: $26,459

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

---

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: 05/31/2022

---