NTSB Supporting Statement A for MEDICAL EXCEPTION REQUEST FORM (ROCIS)

SUPPORTING STATEMENT A
National Transportation Safety Board
NTSB Form: Request for a Medical Exception to the COVID-19 Vaccination Requirement
1.

Circumstances that make the collection of information necessary.
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 and received emergency
clearance in November 2021 for the following form: Request for a Medical Exception to the
COVID-19 Vaccination Requirement. This form is designed for agency employees
requesting a medical exception to the vaccine requirements. The agency has used this form
to determine whether the employee provided sufficient information to justify the request.
Because the OMB number on this form was obtained through emergency clearance,
the OMB number is only valid for six months. In anticipation of future responses from its
employees, the NTSB is submitting this information collection request to extend the validity
of the OMB number associated with this collection.
2.

How, by whom, how frequently, and for what purpose the information will be used.
The answers provided on the Request for a Medical Exception to the COVID-19

Vaccination Requirement form will help the agency to make determinations on requests
from its employees for medical exceptions to the vaccine mandate.
3.
Use of automated, electronic, mechanical, or other technological techniques or other
forms of information technology.
The agency provides a fillable portable document format (PDF) version of the form by email or through its website. A respondent may e-mail the completed form. In turn, the agency
can extract information from the PDF submissions, reducing the need for agency personnel to

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manually enter the information.
To date, most of the respondents have submitted the completed forms electronically and
the agency expects respondents will continue to do so as long as maximum telework remains in
place. Conceivably, once maximum telework ends, there will be some respondents who will
submit their forms either by mail or in person, but the agency predicts that that will only be 10%
of respondents. Accordingly, the NTSB estimates that 90% of respondents will electronically
submit this form.
4.

Efforts to identify duplication.
This information obtained through this collection is unique and is not already available

for use or adaptation from another cleared source.
5.

Small businesses or other small entities.
The agency does not anticipate that there will be a significant burden for any small

business or entity.
6.
Consequences to the Federal program or policy activities if the collection is not
conducted or is conducted less frequently.
If the collection is not conducted or is conducted less frequently, the NTSB will be
delayed in making determinations on requests from its employees for medical exceptions to
the vaccine mandate to meet the requirements of the E.O. and Task Force recommendations.
7.

Special circumstances.
There are no special circumstances requiring respondents to retain records, other than

health or medical records for more than three years.
8.
Federal Register notice, public comments received, and consultation with persons
outside the agency.
Part A: PUBLIC NOTICE
The agency published notices in the Federal Register concerning this collection of

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information. The 60-Day Notice was published in December 2021 with a subsequent correction.
See 86 Fed. Reg. 71676 (Dec. 17, 2021) and 86 Fed. Reg. 73352 (Dec. 27, 2021). The NTSB did
not receive any comments during the comment period. The agency recently submitted its 30-Day
Notice to the Office of Federal Register in March 2022.
Part B: CONSULTATION
Aside from discussions with OIRA personnel, no additional consultation was conducted
for this submission.
9.

Gifts or payments to respondents.
The agency will not provide gifts or payments to respondents for completing the form.

10.

Assurance of confidentiality.
The agency provides assurance of confidentiality to respondents concerning the

completed Request for a Medical Exception to the COVID-19 Vaccination Requirement.
The Privacy Act Statement is located on the first page of the form.
The Systems of Records Notice (SORN) associated with this data collection was
published in the Federal Register on October 11, 2012: “Privacy Act of 1974, as Amended;
Revisions to the Existing System of Records,” 77 Fed. Reg. 62060 (Oct. 11, 2012). The
applicable SORN is NTSB-28, Employee Medical Folders. The SORN is electronically available
at https://www.govinfo.gov/content/pkg/FR-2012-10-11/pdf/2012-24966.pdf.
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not
being collected electronically.
11.

Additional justification for questions of a sensitive nature.
The questions contained in this form are consistent with OMB’s guidance for requesting

a medical exception.
12.

Estimate in hours of the burden of the collection of information.

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The agency estimates that Part 2, which is to be completed by the employee’s medical
provider, takes about 60 minutes to complete, resulting in about 20 burden hours per year. The
estimated time to complete the form includes the time ascertaining and inputting the information.
The form asks for information that is ordinarily maintained by, or readily available to medical
providers. Thus, the estimate does not include hours spent maintaining the information.
The Department of Labor, Bureau of Labor Statistics Occupational Employment and
Wage Statistics (OEWS) Category 20-0000 (Healthcare Practitioners and Technical
Occupations) provides that the median annual salary for healthcare diagnosing or treating
practitioners as of May 20201 was $105,220 with an hourly mean wage of $50.58. Multiplying
this hourly rate by 20 hours equals, when rounded up, $1,012.
13.
Estimate of the total annual cost burden to the respondents or record-keepers
resulting from the collection.
Completion of the form does not require any recordkeeping, capital, start-up, or
maintenance costs, but only requires approximately 60 minutes of a respondents’ time.
14.

Estimates of annualized cost to the Federal government.
The agency incurs costs in transmitting and collecting each form, as well as handling and

analyzing the information in each completed form. The agency estimates a total of 20
respondents will seek a medical exception annually. And thus the NTSB estimates that the total
cost of transmitting and collecting approximately 20 forms annually, when rounded down, will
be $1,316 per year. This amount represents the cost of one hour of processing each form by
agency personnel at agency headquarters. According to the U.S. Office of Personnel
Management, the average hourly rate when rounded up for step 1 of grades 14 and 15 in

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The May 2020 OEWS is the current version available. The May 2021 OEWS data will be released
in Spring 2022.
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Washington, DC is $65.82. 2
In estimating one hour per form, the agency has considered agency personnel’s time in
duties that include, but are not limited to, the following: reviewing the form; verifying,
correcting, and collecting any missing data; scanning, redacting, and loading the form into the
agency’s database; and adjudicating the request. Accordingly, the agency estimates that the
complete annualized cost to the Federal government will be $1,316.
15.

Program changes or adjustments.
No changes or adjustments will occur to any programs.

16.

Plans for tabulation and publication of responses.
The results of this information collection will not be published.

17.

Display of expiration date.
The agency will display the expiration date of OMB’s approval.

18.

Exception to certification statement in Form 83-I.
The agency does not request any exception to the certification statement contained in

Item 19 of OMB Form 83-I.

2

https://www.opm.gov/policy-data-oversight/pay-leave/salaries-wages/salarytables/22Tables/html/DCB_h.aspx.
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