Request for a Religious Exception to the COVID-19 Vaccin

REQUEST FOR A RELIGIOUS 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. In certain circumstances, Federal law may entitle a Federal
employee who has a religious objection to the COVID-19 vaccination requirement to an exception from that
requirement, in which case the employee would instead comply with alternative health and safety protocols. The
Federal Government is committed to respecting the important legal protections for religious liberty.
In order to request a religious exception, please fill out this form and attach a separate document with your
responses to the questions below. The purpose of this form is to start the accommodation process and help the
U.S. Merit Systems Protection Board (MSPB) determine whether you may be eligible for a religious exception. You
do not need to answer every question on the form to be considered for a religious exception, but we encourage
you to provide as much information as possible to enable MSPB to evaluate your request. Where there is an
objective basis to do so, MSPB may ask you for additional information as needed to determine if you are legally
entitled to an exception. Objections to COVID-19 vaccinations that are based on non-religious reasons, including
personal preferences or non-religious concerns about the vaccine, do not qualify for a religious exception.
Agencies may consider several factors in assessing whether a request for an exception is based on a sincerely
held religious belief, including whether the employee has acted in a manner inconsistent with their professed
belief. But no one factor is determinative. An individual’s beliefs—or degree of adherence—may change over time
and, therefore, an employee’s newly adopted or inconsistently observed practices may nevertheless be based on
a sincerely held religious belief. All requests for a religious exception will be evaluated on an individual basis.
Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge
and ability, true and correct. Any intentional misrepresentation to the Federal Government may result in legal
consequences, including termination or removal from Federal service.
QUESTIONS:
1. Please describe the nature of your objection to the COVID-19 vaccination requirement.
2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise
or conflict with your sincerely held religious beliefs, practices, or observances? If so, please explain how.
3. Please provide any additional information that you think may be helpful in reviewing your request. For
example:
• How long have you held the religious belief underlying your objection?
• Whether your religious objection is to the use of all vaccines, COVID-19 vaccines, a specific type of
COVID-19 vaccine, or some other subset of vaccines.
• Whether you have received vaccines as an adult against any other diseases (such as a flu vaccine or
a tetanus vaccine).
I declare to the best of my knowledge and ability that the foregoing is true and correct.
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Print Name

Signature

Date

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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. The authority for this form is
also derived from Title VII of the Civil Rights Act of 1964, 42 U.S.C. 2000e; 29 C.F.R. 1605 (Guidelines on
Discrimination Because of Religion).
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 religious
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 the
Centers for Disease Control and Prevention, 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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