Medical Exception to COVID Vaccination Requirement

DEPARTMENT OF THE TREASURY
WASHINGTON, D.C. 20220

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 agency 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. The agency 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.
You may use this form to request a medical exception or delay from the COVID-19 vaccination. If you
choose not to use this form, you are expected to communicate the specific information identified in the
form. You may also be asked to provide additional information necessary to make a decision.

1. Part 1 of the form is information to be provided by you.
2. Part 2 of the form is information to be provided by your medical professional.
3. Provide both parts 1 and 2 to the Disability Accommodation Coordinator at: [email protected]

Privacy Act Statement
Authority: Solicitation of this information is authorized by the Rehabilitation Act of 1973, §§
501 and 504; Title VII of the Civil Rights Act of 1964, as amended; Executive Order 13164 (July
28, 2000); and Executive Order 14043 (September 09, 2021).
Purpose: The Department of the Treasury (Treasury) is collecting the information to support its
review of reasonable accommodation requests. The information provided will help Treasury
process requests for medical accommodation or exception to the COVID-19 vaccination
requirement due to temporary or long-term condition or medical circumstance. Additionally,
the information collected will allow Treasury to track and report the processing of requests for
reasonable accommodations Treasury-wide to comply with applicable laws and regulations.
Routine Uses: While the information requested on this form is intended to be used primarily
for internal purposes, in certain circumstances it may be necessary to disclose this information
externally pursuant to certain routine uses. For example the information may be disclosed to:
a congressional office in response to an inquiry from the congressional office made at the
request of the employee providing the information on this form; to an authorized
administrative judge, equal employment opportunity investigator, arbitrator or other duly
authorized official engaged in investigation or settlement of a grievance, complaint or appeal
filed by an employee; or to medical personnel to address a bona fide medical emergency. A
complete list of the routine uses pursuant to which this information may be shared can be
found in the system of records notice associated with this collection of information,
Treasury .016 Reasonable Accommodations Records, available at 81 FR 78266 (Nov. 11, 2016).
Disclosure: Providing this information is voluntary. However, failure to furnish the requested
information may delay or prevent action on your reasonable accommodation request.

Part 1 – REQUEST (To be completed by employee)
1b. Line of Business and Job Title

1a. Employee Name

1c. Official Duty Station (Name of Office, City & State
1e. Supervisor

1d. Telework Location (City & State)

1f. Employee Email Address

1g. Employee Phone Number

1h. Medical 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.

1i. Employee Signature
1j. Date Requested (may differ from date signed)

1k. Reference # (to be completed by DAC)

Part 2 – MEDICAL CERTIFICATION (To be completed by employee's medical professional)
2a. Employee Name
2b. Medical Certification for COVID-19 Vaccine Exception
Dear Medical Professional:
The Office of the Comptroller of the Currency (OCC) requires its employees to be fully vaccinated
against COVID-19 pursuant to Executive Order 14043 issued by the President of the United States.
The individual named above is seeking a medical exception to the requirement for COVID-19
vaccination or a delay because of a temporary condition or medical circumstance. Please complete
this form to assist the OCC in its reasonable accommodation process. If you have questions, please
contact the OCC's Disability Accommodation Coordinator: [email protected] or (202)
704-9488. 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.
2c. Description of the medical condition for which the employee should be excepted from complying
with a COVID-19 vaccination requirement. (Provide as an attachment.)

2d. The condition described above is:
CHECK ONE

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):
Date:
2e. Medical Professional Name and Title
2f. Medical Professional Signature

2g. Date Signed

Part 3 -- DECISION & RIGHTS (To be completed by OCC and issued to employee)
There is no reconsideration process. If you disagree with this decision and wish to pursue your
administrative, statutory or collective bargaining rights, you must:
1. EEO Complaint: Initiate the EEO pre-complaint process by contacting the OCC's EEO
Officer within 45 calendar days from the date of your receipt of a written decision; or
2. Negotiated Grievance: If a bargaining unit employee, file a written grievance within 20
business days from the date of your receipt of a written decision, and in accordance with
the provisions of the Collective Bargaining Agreement.
If your exception request is denied, you must receive the first dose of the vaccine (or second dose if
first already received) within two weeks of receiving a denial in writing. If you fail to comply with the
Executive Order, you will be subject to disciplinary action up to and including removal. Should you
file an EEO complaint or grievance on the denial of your exception request, it will not stop the OCC
from taking disciplinary action against you. If the OCC decides to take disciplinary action, any written
notice(s) issued to you will include your administrative, statutory or collective bargaining rights.

Approved under the following condition(s):

Denied for the following reason(s):

_________________________________

_________________________________

Deciding Official Signature

Reference #
Date Issued to Employee: