USPTO-OEEOD 303 COVID-19 Vaccine Supplemental Medical Provider Statement

CUI//SP-HLTH/SP-PERS/SP-PRVCY (CUI When Filled In/Populated)

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Office of Equal Employment Opportunity and Diversity

Employee Name:
REQUEST FOR REASONABLE ACCOMMODATION – COVID-19 VACCINE
SUPPLEMENTAL MEDICAL PROVIDER STATEMENT
(to be completed by Medical Provider)

The United States Patent and Trademark Office (USPTO) requires its employees to be
fully vaccinated against COVID-19 pursuant to Executive Order 14043. The employee
named above is seeking a medical exception to the requirement for COVID-19
vaccination or a delay because of a medical condition or circumstance. Please
complete this form to assist the USPTO in its reasonable accommodation process. If
you have questions about completing this form, please contact the USPTO’s
Reasonable Accommodation Coordinator at 571-272-8292 or [email protected].
Be sure to sign the form and include your office address and telephone number.
The completed form and any attachments should be returned to the employee.
The employee will email them (encrypted) to the assigned Reasonable
Accommodation Specialist.
*Please note the following:
The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits
employers and other entities covered by GINA Title II from requesting or requiring
genetic information of an individual or family member of the individual, except as
specifically allowed by this law. “Genetic information,” as defined by GINA,
includes an individual’s family medical history, the results of an individual’s or
family member’s genetic tests, the fact that an individual or an individual’s family
member sought or received genetic services, and genetic information of a fetus
carried by an individual or an individual’s family member or an embryo lawfully
held by an individual or family member receiving assistive reproductive services.
To comply with this law, the Agency requests that you do not provide any genetic
information when responding to this request for medical information.

USPTO-OEEOD Form 303 (November 2021)

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1. A. Describe the medical condition for which the employee named above should be
excepted from complying with the COVID-19 vaccination requirement.

B. Identify the specific contraindication(s) or precaution(s) for COVID-19 vaccination
that are applicable to the employee. For each contraindication or precaution,
indicate: (a) whether it is recognized by the Centers for Disease Control and
Prevention (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. The list of currently approved
and authorized vaccines is available at https://www.cdc.gov/coronavirus/2019ncov/vaccines/different-vaccines.html.

C. If the employee’s condition is such that COVID-19 vaccination is not considered
saf e, indicate the specific nature of the condition that contraindicates immunization
with a COVID-19 vaccine or that might increase the risk for a serious adverse
r eaction.

D. Describe any other medical condition that would limit the employee from receiving
any COVID-19 vaccine.

USPTO-OEEOD Form 303 (November 2021)

CUI//SP-HLTH/SP-PERS/SP-PRVCY (CUI When Filled In/Populated)

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2. The condition described above is:
☐ temporary
☐ permanent
If this is a temporary condition, when it is expected to end or expire (allowing for
COVID-19 vaccination to begin after the date you provide):

I certify that all the statements made on this Supplemental Medical Provider’s
Statement are true to the best of my knowledge and belief.
Medical Provider’s Signature:
Date:
Medical Provider’s Name (Type or Print Legibly):
Office Address:

USPTO-OEEOD Form 303 (November 2021)

Office Telephone Number:

City/State/ZIP Code:

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PRIVACY ACT STATEMENT
The Privacy Act of 1974, as amended (5 U.S.C. 552a), requires that you be given certain information
about this form. The authority for this Request for a Reasonable Accommodation to the COVID-19
Vaccination Requirement is derived from Executive Order 14043, Requiring Coronavirus Disease 2019
Vaccination for Federal Employees (Sept. 9, 2021), and Title VI of the Civil Rights Act of 1964, as
amended, 42 U.S.C. § 2000e et seq. The information in this system is used to decide on requests for
accommodation, any subsequent complaints of alleged discrimination, and possibly to evaluate the
effectiveness of the EEO program. The collection of this information is authorized by the Equal
Employment Opportunity Act of 1972, 42 U.S.C. § 2000e-16, as amended. The Agency will maintain a
record of all accommodation requests, including this form, which will be utilized to determine the efficacy
and consistency of the reasonable accommodation process. As a routine use, this information may be
disclosed to an appropriate government agency, domestic or foreign, for law enforcement purposes;
where pertinent, in a legal proceeding to which the Agency is a party or has an interest; to a government
agency in order to obtain information relevant to an Agency decision concerning employment, security
clearances, contracts, licenses, grants, permits or other benefits; to a government agency upon its
request when relevant to its decision concerning employment, security clearances, security or suitability
investigations, contracts, licenses, grants or other benefits; to a congressional office at your request, to an
expert, consultant or other person under contract with the Agency to fulfill an agency function; to the
National Archives and Records Administration for records management activities; to the Office of
Management and Budget for review of private relief legislation; to an independent certified public
accountant during an official audit of Agency finances; to an investigator, administrative judge or
complaints examiner appointed by the Equal Employment Opportunity Commission for investigation of a
formal EEO complaint under 29 CFR Part 1614; to the Merit Systems Protection Board or Office of
Special Counsel for proceedings or investigations involving personnel practices and other matters within
their jurisdiction; and to a labor organization as required by the Federal Service Labor-Management
Relations Statute. The applicable System of Records Notices for this information are:
COMMERCE/DEPT-18, Employees Personnel Files Not Covered by Notices of Other Agencies, Except
as Prohibited by Law (72 FR 6200 / February 9, 2007 / available at:
https://www.osec.doc.gov/opog/PrivacyAct/SORNs/DEPT-18.html) and EEOC/GOV-1, Equal Employment
Opportunity in the Federal Government Compliant and Appeal Records (67 FR 49354 / July 30, 2002 /
available at: https://www.osec.doc.gov/opog/PrivacyAct/sorns/GOV-Wide/EEOC-GOV1-18895.pdf).
Completion of this form is voluntary; however, an accommodation may be denied to a qualified individual
without this written information.
USPTO Privacy Policy: https://www.uspto.gov/privacy-policy
PAPERWORK REDUCTION ACT STATEMENT
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with an information collection subject to the
requirements of the Paperwork Reduction Act of 1995, unless the information collection has a valid OMB
Control Number. The OMB Control Number for this information collection is 0651-0087. Public burden for
this form is estimated to average 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the information collection. Send comments regarding this burden estimate or any other aspect
of this information collection, including suggestions for reducing this burden to the Office of the Chief
Administrative Officer, United States Patent and Trademark Office, P.O. Box 1450, Alexandria, VA
22313-1450 or email [email protected].

USPTO-OEEOD Form 303 (November 2021)