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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction	Unchanged	Repair queued
NTSB Supporting Statement A for MEDICAL EXCEPTION REQUEST FORM (ROCIS).pdf	Supporting Statement A	Uploaded 2022-03-22	Repair queued
NTSB FORM Request for Medical Exception with OMB number and May 2022 expiration date (ROCIS).pdf	Supplementary Document	Uploaded 2022-03-22	Repair queued
NTSB FORM Request for Medical Exception.pdf	Supplementary Document	Uploaded 2021-11-01	Repair queued
NTSB EMERGENCY JUSTIFICATION LETTER for Medical Exception Request Form.pdf	Supplementary Document	Uploaded 2021-11-01	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250005	Request for a Medical Exception to the COVID-19 Vaccination Requirement	Form and Instruction	Unchanged

ICR Details

OMB Control No: 3147-0028	ICR Reference No: 202203-3147-001
Status: Received in OIRA	Previous ICR Reference No: 202111-3147-001
Agency/Subagency: NTSB	Agency Tracking No:
Title: Request for a Medical Exception to the COVID-19 Vaccination Requirement
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/22/2022

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2022
Responses	20	20
Time Burden (Hours)	20	20
Cost Burden (Dollars)	1,012	1,012

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Abstract: To comply with the September 9, 2021, Executive Order (E.O.) 14043 (Requiring Coronavirus Disease 2019 Vaccination for Federal Employees) and October 2021 guidance from the Safer Federal Workforce Task Force, the NTSB created the following form: Request for a Medical Exception to the COVID-19 Vaccination Requirement. The agency will use this form to determine whether the employee provided sufficient information to justify the request. Because the OMB number assigned to this form was obtained through emergency clearance, the OMB number is only valid for six months and will expire on May 31, 2022. In anticipation of future requests from its employees, the NTSB is specifically seeking an extension of this currently-approved collection.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 71676	12/17/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 16245	03/22/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination Requirement	N/A	Request for a Medical Exception to the COVID-19 Vaccination Requirement

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ICR Summary of Burden

table that charts list of burden

	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	20	20	0	0	0	0
Annual Time Burden (Hours)	20	20	0	0	0	0
Annual Cost Burden (Dollars)	1,012	1,012	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,278

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 03/22/2022

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