Request for a Medical Exception to the COVID-19 Vaccinat

National Transportation Safety Board
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.
Instructions
1. Complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, submit to [email protected].
Privacy Act Statement
Authority: Pursuant to Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sept.
9, 2021), we are authorized to collect this information.
Purpose: This information is being collected and maintained to promote the safety of Federal workplaces and the Federal
workforce consistent with the above-referenced authority Executive Order 14043, which requires mandatory vaccinations
for all federal employees with exceptions only as required by law.
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 (e.g., the Merit System Protection
Board), 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. See NTSB-28, Employee Medical Folders.
Consequence of Failure to Provide Information: If you are requesting a medical or religious exception to the requirement
that you be vaccinated for the COVID-19 virus, providing the requested information is mandatory. Unless granted a legally
required exception, all covered Federal employees are required to be vaccinated against COVID-19 and to provide
documentation concerning their vaccination status to their employing agency. Unless you have been granted a legally
required exception, failure to provide this information may subject you to disciplinary action, including and up to removal
from Federal service.

Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Office/Region

Division

Position

Supervisor

Phone Number

Medical or Disability 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.

Employee Signature
Print Name

Date

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The National Transportation Safety Board (NTSB) requires its employees pursuant to Executive
Order of the President of the United States to be fully vaccinated against COVID-19. 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 NTSB in its reasonable accommodation process. If you have questions about completing this
form, please contact Fara Guest, NTSB’s reasonable accommodation coordinator, at
[email protected] or 202-314-6190.
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.
Description of the medical condition for which the employee listed above should be
excepted from complying with a COVID-19 vaccination requirement:

The condition described above is:

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):

Medical Provider Name/Title
Medical Provider Signature

FORM APPROVED FOR USE THROUGH [Insert date issued by OIRA]
BY OMB NO. _____________________
You need not complete this form unless it displays a valid OMB control number.

Date