Mspbem~2

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions

OMB Control Number: 3124 – 0NEW
Title:

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

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.
Justification
1. Circumstances that make the collection of information necessary.
Consistent with guidance from the Centers for Disease Control and Prevention (CDC), guidance
from the Safer Federal Workforce Task Force, established pursuant to Executive Order 13991,
“Protecting the Federal Workforce and Requiring Mask-Wearing” (Jan. 20, 2021), and Executive
Order 14043, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees” (Sept. 9,
2021), the request for this collection of information is essential to implement MSPB’s health and
safety measures regarding Federal employees seeking medical or religious exceptions to the
mandatory COVID-19 vaccination requirement.
Title V of the Rehabilitation Act of 1973 (Rehabilitation Act), as amended, prohibits
discrimination in services and employment on the basis of disability, and Title VII of the Civil
Rights Act of 1964 (Civil Rights Act) prohibits discrimination, including on the basis of religion.
These prohibitions on discrimination require Federal agencies to provide reasonable
accommodations to individuals with disabilities and those with sincerely held religious beliefs
unless doing so would impose an undue hardship. In some instances, individuals may request
modifications to their workspace, schedule, duties, or other requirements for documented medical
reasons that may not qualify as a disability but may necessitate an appropriate modification to
workplace policies and practices. See, The Rehabilitation Act of 1973, 29 U.S.C. 701, 791, 794;
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); 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).
Section 2 of Executive Order 14043 mandates that “[e]ach agency shall implement, to the extent
consistent with applicable law, a program to require COVID-19 vaccination for all of its Federal

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions
employees, with exceptions only as required by law.” As such, the two forms in this ICR are
necessary for MSPB to determine whether individuals are exempt, pursuant to the Rehabilitation
Act and the Civil Rights Act, from the vaccine requirement in Executive Order 14043.
MSPB has an urgent need to request medical and religious exemption information from its Federal
employees with input from the individual’s medical provider and/or religious or spiritual advisor.
Therefore, complying with the normal PRA clearance procedures is likely to cause harm because
of the threat of COVID-19 exposure and transmission.
2. How the information will be used.
The Request for Medical and Religious Exception to the COVID-19 Vaccination Requirement
forms will be used by MSPB to make determinations on requests by employees or prospective
employees to be exempt from the vaccine mandate established by Executive Order 14043 for
medical or religious reasons.
3. Use of automated collection procedures.
The forms are in a fillable electronic format that can also be printed out to be manually completed.
A link to the forms will be available on MSPB’s internal SharePoint site and available to
prospective employees upon request. Additionally, the forms may also be emailed to respondents
upon request. All forms must be submitted to the assigned MSPB Reasonable Accommodation
Coordinator, which will then be provided to MSPB’s Director of the Office of Equal Employment
Opportunity.
4. Efforts to identify duplication.
The requested information is unique to each individual request, and MSPB is unaware of any other
sources of similar information.
5. Impact to small businesses.
The collection of information may impact medical providers or religious or spiritual advisors who
qualify as a small business because the forms require information to be submitted by them. The
burden is minimized for the entities and/or individuals because the forms request a limited amount
of information and can be completed and submitted electronically.
6. Consequences of not collecting the information.
Not collecting this information would inhibit MSPB’s ability to meet the requirements of the
Rehabilitation Act, the Civil Rights Act, Executive Order 14043, and guidance from the Safer
Federal Workforce Task Force.

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions
7. Explanation of special circumstances.
Respondents will be required to prepare a written response to this collection of information in
fewer than 30 days after receipt of it to meet the deadlines set by Executive Order 14043.
There are no special circumstances that would cause the information collected to be conducted in
a manner:
•

requiring respondents to report information to the agency more often than quarterly;

•

requiring respondents to submit more than an original and two copies of any document;

•

requiring respondents to retain records, other than health, medical, government contract,
grant-in-aid, or tax records, for more than three years;

•

in connection with a statistical survey, that is not designed to produce valid and reliable
results that can be generalized to the universe of study;

•

requiring the use of a statistical data classification that has not been reviewed and
approved by the Office of Management and Budget (OMB);

•

that includes a pledge of confidentiality that is not supported by authority established in
statute or regulation, that is not supported by disclosure and data security policies that are
consistent with the pledge, or which unnecessarily impedes sharing of data with other
agencies for compatible confidential use; or

•

requiring respondents to submit proprietary trade secrets, or other confidential
information unless the agency can demonstrate that it has instituted procedures
to protect the information's confidentiality to the extent permitted by law.

8. Federal Register Notice.
MSPB is seeking emergency clearance in accordance with the emergency review procedures set
forth under 5 C.F.R. §1320.13 and waiving the notice requirement under the emergency clearance
as set forth in 5 C.F.R. §1320.13(d). After emergency clearance is obtained, MSPB will submit
the ICR for review under the normal clearance procedures allowing for public review and
comment.
Aside from discussions with OMB personnel and other Federal agencies, no additional
consultation was conducted for this submission.
9. Payment or gift to respondents.
No payment or gifts of any kind have been provided to any individuals who are connected to this
collection.

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions
10. Assurance of confidentiality.
This collection of information is covered under MSPB – 3, Reasonable Accommodations, MSPB3 Reasonable Accommodations SORN, 86 Fed. Reg. 73001 (Dec. 23, 2021).
The forms provide the required Privacy Act statement under 5 U.S.C. § 552a(e)(3).
A Privacy Impact Assessment was approved on January 3, 2022.
11. Justification for any questions of a sensitive nature.
Pursuant to and consistent with the Rehabilitation Act and Equal Employment Opportunity
Commission regulations, MSPB is authorized to and required to ask questions regarding the
medical condition of the individuals requesting a reasonable accommodation for medical reasons.
Additionally, the Civil Rights Act prohibits employment discrimination based on religion. This
includes a right for job applicants and employees to request a reasonable accommodation from an
employer requirement that conflicts with their sincerely held religious beliefs, practices, or
observances. For MSPB to evaluate these requests, we are authorized to collect information to
determine whether the job applicant or employee has a sincerely held religious belief, practice or
observance to qualify for a reasonable accommodation.

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions
12. Estimates of annualized costs for collection of information.
Estimated Annualized Burden Hours and Costs
No. of
Avg.
Total
Responses
Total No. Burden per Annual
Type of
Form Name /
No. of
of
per
Response Burden (in
Respondents Respondent Responses (in hours)
Respondent
Form No.
hours)

Avg.
Hourly
Wage
Rate

Request for a
Medical
Part 1
Exception to
Applicant the COVID-19
for
Vaccination
Employment Requirement

10

1

10

1.00

10.00

37.9

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

50

1

50

1.00

50.00

141.99

Request for a
Religious
Exception to
Applicant the COVID-19
for
Vaccination
Employment Requirement

10

1

10

1.00

Part 2
Medical
Provider

10.00
37.9
0.00
0.00
0.00
0.00
0.00
Total
70
70
70.00
Note: The “Avg. Hourly Wage Rate” for each respondent includes a 1.4 multiplier to reflect a fully-loaded wage rate.

Total
Annual
Respondent
Cost

$

379.00

$ 7,099.50

$
379.00
$
$
$
$
$
$ 7,857.50

According to the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov) the
wage rate category for General Internal Medicine Physicians is estimated to be $141.99 per hour
including the wage rate multiplier, therefore, the estimated burden hour cost to respondents
Medical Provider is estimated to be $7,099.50 annually.
According to the U.S. Department of Labor, Bureau of Labor Statistics website (www.bls.gov) the
wage rate category for All Occupations is estimated to be $37.90 per hour including the wage rate
multiplier, therefore, the estimated burden hour cost to respondents Medical Provider is estimated
to be $379 annually for each form.

U.S. Merit Systems Protection Board

Supporting Statement A for Paperwork Reduction Act Submissions
13. Total costs to respondents or record keepers.
There are no annualized costs to respondents other than the labor burden costs addressed in Section
12 of this document to complete this collection
14. Estimates of annualized costs to the Federal Government.
Annual Cost to the Federal Government
Item

Contract Costs
Staff Salaries* [One GS 14, step 5 employee spending approximately 30% of their time
annually processing reasonable accommodation requests: $138,866*30%= $41,659.80]
Facilities [cost for renting, overhead, etc., for data collection activity]
Computer Hardware and Software [cost of equipment annual lifecycle]
Equipment Maintenance [cost of annual maintenance/service agreements for equipment]
Travel
Total
* Note: The “Salary Rate” includes a 1.4 multiplier to reflect a fully-loaded wage rate.

$
$

$

Cost ($)

0
0
0
0

-

41,659.80

41,659.80

15. Explanation of program changes or adjustments.
Not applicable. This is a new information collection.
16. For collections of information whose results will be published, outline plans for
tabulation and publication.
There are no outline plans for tabulation and publication of data for this information collection.
17. If seeking approval to not display the expiration date for OMB approval of the
information collection, explain the reasons that display would be inappropriate.
This collection does not seek approval to not display the expiration date for OMB approval.
18. Explain each exception to the topics of the certification statement identified in
“Certification for Paperwork Reduction Act Submissions.”
This collection does not seek exception to “Certification for Paperwork Reduction Act
Submissions”.