Request for a Medical Exception to the COVID-19 Vaccinat

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

Request for a Medical Exception to the COVID-19 Vaccination Requirement (Final)

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

OMB: 3124-0016

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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 Merit Systems Protection Board
(MSPB) 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. MSPB 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 MSPB’s designated point of
contact.

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OMB No. 3124-XXXX
Expiration 6-30-2022

Privacy Act Statement
Authority: Pursuant to 5 U.S.C. chapters 11 and 79, and in discharging the functions directed under Executive
Order 14043, "Requiring Coronavirus Disease 2019 Vaccination for Federal Employees" (Sept. 9, 2021), we are
authorized to collect this information. The authority for the system of records notice (SORN) associated with
this collection of information, MSPB-3 Reasonable Accommodations SORN, 86 Fed. Reg. 73001 (Dec. 23, 2021),
also includes 5 U.S.C. chapters 33 and 63 and Executive Order 12196, "Occupational Safety and Health
Program for Federal Employees" (Feb. 26, 1980). The authority for this form is also derived from the
Rehabilitation Act of 1973, 29 U.S.C. 701, 791, 794; 29 C.F.R. 1614 (Federal Sector Equal Employment
Opportunity); 29 C.F.R. 1630 (Regulations To Implement the Equal Employment Provisions of the Americans
With Disabilities Act); Executive Order 13164, "Requiring Federal Agencies to Establish Procedures to Facilitate
the Provision of Reasonable Accommodation" (July 26, 2000); and Executive Order 13548, "Increasing Federal
Employment of Individuals with Disabilities" (July 26, 2010).
Purpose: The purpose of this system of records is to allow the U.S. Merit Systems Protection Board (MSPB) to
collect and maintain records on applicants for employment and employees who request or receive reasonable
accommodations or other appropriate modifications from MSPB for medical reasons; to process, evaluate, and
make decisions on individual requests; to track and report the processing of such requests to comply with
applicable requirements in law, regulation, and policy; and to maintain the confidentiality of the information
provided in support of the accommodation. This information is being collected and maintained to promote
the safety of Federal workplaces and the Federal workforce consistent with the above-referenced authorities,
Executive Order 13991, "Protecting the Federal Workforce and Requiring Mask-Wearing" (Jan. 20, 2021), and
guidance from Centers for Disease Control and Prevention (CDC), the Safer Federal Workforce Task Force, and
the Occupational Safety and Health Administration.
Routine Uses: While the information requested is intended to be used primarily for internal purposes, in
certain circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work environment; to
adjudicative bodies, arbitrators, and hearing examiners to the extent necessary to carry out their authorized
duties regarding Federal employment; to contractors, grantees, or volunteers as necessary to perform their
duties for the Federal Government; to other agencies, courts, and persons as necessary and relevant in the
course of litigation, and as necessary and in accordance with requirements for law enforcement; or to a
person authorized to act on your behalf. A complete list of the routine uses can be found in the SORN
associated with this collection of information.
Consequence of Failure to Provide Information: Providing this information is voluntary. Failure to provide this
information may delay or impede the processing of this reasonable accommodation request. Moreover,
without an approved reasonable accommodation request, failure to provide proof of COVID-19 vaccination
may result in disciplinary measures, up to and including removal from Federal service, based on the
requirements of Executive Order 14043, "Requiring Coronavirus Disease 2019 Vaccination for Federal
Employees" (Sept. 9, 2021).
Burden Statement
Public reporting burden for this data collection is estimated to vary from 10 minutes to 1 hour, with an
average of 60 minutes per response. The burden estimate includes the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and submitting
this form. You are not required to respond to this collection of information unless a valid Office of
Management and Budget (OMB) control number is displayed on this form. Send comments regarding the
burden estimate or any other aspect of the collection of information, including suggestions for reducing this
burden, to Office of the Clerk of the Board, Merit Systems Protection Board, 1615 M Street, NW, Washington,
DC 20419; by fax to 202-653-7130; or by e-mail to [email protected]

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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

3

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The U.S. Merit Systems Protection Board requires its employees to be fully vaccinated against COVID-19
pursuant Executive Order of the President of the United States. The individual named above is seeking a
medical exemption to the requirement for COVID-19 vaccination or a delay because of a temporary
condition or medical circumstance. Please complete this form to assist MSPB in its reasonable
accommodation process. If you have questions about completing this form, please contact MSPB’s
EEO Director at [email protected] or 202-254-4405.
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

4


File Typeapplication/pdf
File TitleMSPB Medical Exception Request Form
SubjectCOVID-19 Vaccination Exception--Requests On Medical Grounds
AuthorJess Lang
File Modified2022-01-06
File Created2021-10-04

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