Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement	Form and Instruction	New	Missing upstream
MSPB Emergency Clearance Request for Medical and Religious Exception Form 83-I (Signed).pdf	Supplementary Document	Uploaded 2022-01-06	Missing upstream
MSPBEM~3.PDF	Supplementary Document	Uploaded 2022-01-06	Repair queued
MSPBEM~2.PDF	Supporting Statement A	Uploaded 2022-01-06	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
251045	Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202201-3124-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: MSPB	Agency Tracking No:
Title: Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 01/10/2022
Date Submitted to OIRA: 01/06/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	70	0
Time Burden (Hours)	70	0
Cost Burden (Dollars)	0	0

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Abstract: This Information Collection Request (ICR) seeks an emergency Paperwork Reduction Act (PRA) clearance to allow the U.S. Merit Systems Protection Board (MSPB) to collect information from individuals applying for an exception to the mandatory COVID-19 vaccination under Executive Order 14043, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees” (Sept. 9, 2021). MSPB is unable to comply with the normal PRA clearance procedures given the critical role of the collection of information to meeting our commitments under Executive Order 14043.

Emergency Justfication: This information is essential to implement health and safety measures mandated by Executive Order 14043, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees” (Sept. 9, 2021) and included within recent Safer Federal Workforce Task Force Guidance. Government agencies have an urgent need to request medical and religious exception information from federal employees with input from medical professionals and religious or spiritual advisors. Applying regular Paperwork Reduction Act clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission (5 C.F.R. § 1320.13(a)(2)(i)).

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees” (Sept. 9, 2021)
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement	n/a, n/a	Request for a Medical Exception to the COVID-19 Vaccination Requirement ,   Request for a Religious Exception to the COVID-19 Vaccination Requirement

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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	70	0	0	70	0	0
Annual Time Burden (Hours)	70	0	0	70	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $41,659

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

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Common Form ICR:  No

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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: 01/06/2022

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