Medical Exception Request to the COVID-19 Vaccination Requirement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form FMSHRC-09-002 Medical Exception Request to the Vaccination Requirement	Form and Instruction	Modified	Available
Form FMSHRC-09-001 FMSHRC Medical Exception Request Form	Form and Instruction	Modified	Available
Form FMSHRC-09-001 FMSHRC Medical Exception Request Form	Form and Instruction	Modified	Available
2022-4-28 FMSHRC Transmittal Letter to OIRA.pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
2021-11-22 FMSRHC Transmittal Letter to OIRA .docx	Supplementary Document	Uploaded 2021-11-23	Repair queued
2021-11-22 FMSRHC Transmittal Letter to OIRA .docx	Supplementary Document	Uploaded 2021-11-22	Repair queued
2022-4-28 FMSHRC Transmittal Letter to OIRA.pdf	Supporting Statement A	Uploaded 2022-04-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250495	FMSHRC Medical Exception Request Form	Form and Instruction	Modified	Medical Exception Request to the Vaccination Requirement
250495	FMSHRC Medical Exception Request Form	Form and Instruction	Modified	FMSHRC Medical Exception Request Form
250495	FMSHRC Medical Exception Request Form	Form and Instruction	Modified

ICR Details

OMB Control No: 3079-0001	ICR Reference No: 202201-3079-001
Status: Historical Active	Previous ICR Reference No: 202111-3079-001
Agency/Subagency: FMSHRC	Agency Tracking No:
Title: Medical Exception Request to the COVID-19 Vaccination Requirement
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/06/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/28/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2025	36 Months From Approved	06/30/2022
Responses	6	0	6
Time Burden (Hours)	24	0	24
Cost Burden (Dollars)	600	0	600

---

Abstract: In order to ensure the health and safety of the Federal workforce and the efficiency of the civil service, full Coronavirus Disease 2019 Vaccination was made mandatory for all Federal employees, with exceptions only required by law, under Executive Order 14043. Subsequently, a federal court imposed an injunction preventing the federal government from enforcing mandatory vaccination. However, because the Information Collection form for seeking a Reasonable Accommodation to the vaccination had already been approved by OMB for FMSHRC use prior to the court injunction, FMSHRC is seeking to renew the ICR in the event that the injunction is lifted or further COVID-19 vaccinations are required during the period that an approved ICR Renewal would be in effect. In the event that vaccinations may be required, requests for “medical accommodation” or “medical exceptions” will be treated as requests for 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 per guidance provided by the Safer Federal Workforce Task Force.

---

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: Rehabilitation Act Section 501
  

Citations for New Statutory Requirements: EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees

---

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 17	01/26/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 19513	04/04/2022
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
FMSHRC Medical Exception Request Form	FMSHRC-09-001, FMSHRC-09-002	FMSHRC Medical Exception Request Form ,   Medical Exception Request to the Vaccination Requirement

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	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	6	6	0	0	0	0
Annual Time Burden (Hours)	24	24	0	0	0	0
Annual Cost Burden (Dollars)	600	600	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: $999

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: 04/28/2022

---