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

ICR 202201-3240-001

OMB: 3240-0040

Federal Form Document

Forms and Documents
Document
Name
Status
Supplementary Document
2022-01-12
Supplementary Document
2022-01-12
Supporting Statement A
2022-01-12
IC Document Collections
ICR Details
202201-3240-001
Received in OIRA
SSS
Request for a Medical Exception to the COVID-19 Vaccination Requirement
New collection (Request for a new OMB Control Number)   No
Emergency 01/14/2022
01/13/2022
  Requested Previously Approved
6 Months From Approved
8 0
20 0
0 0

Consistent with Executive Order 14043, of September 9, 2021, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, and included within the Safer Federal Workforce Task Force Guidance mandating all Federal employees be vaccinated by November 22, 2021, the Selective Service System (SSS) has established specific safety protocols for individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who are not fully vaccinated against COVID-19 by November 22, 2021, or who choose not to provide this information will be required to comply with applicable OMB, OPM and SSS guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements. SSS employees may request an exemption on the basis of a medical condition or circumstance. Exemptions will be granted in limited circumstances and only where legally required. The Medical Exception Form will be provided directly to the individuals who are requesting a medical exemption.
SSS is seeking approval of the form, “Request for a Medical Exception Form to the COVID-19 Vaccination Requirement,” which will be completed by employees who seek a medical exemption. SSS seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing. The Form will be used by SSS staff and provided to employees to ensure they submit adequate information to support the exemption request. This form will also ensure the information collected is consistent among the components and minimize the need to seek additional evidence. Rendered decisions should be in accordance with guidelines established by the Safer Federal Workforce Task Force Guidance.

EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  
None

Not associated with rulemaking

No

1
IC Title Form No. Form Name
Requiring Coronavirus Disease 2019 Vaccination for Federal Employees

  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 8 0 0 8 0 0
Annual Time Burden (Hours) 20 0 0 20 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new request resulting in a program change of 20 burden hours.

No
    Yes
    Yes
No
No
No
Yes
Betty Lou Wingo 703 605-4005 [email protected]

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
01/13/2022


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