Request for Medical Exception to COVID-19 Vaccination Requirement

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Part II Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction	Modified	Available
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement, Part I	Form and Instruction	Modified	Available
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction	Modified	Repair queued
Vaccine Requirement Exemption ICR Supporting Statement 2022.03.docx	Supporting Statement A	Uploaded 2022-04-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
250509	Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction	Modified	Request for Medical Exception to COVID-19 Vaccination Requirement
250509	Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction	Modified	Request for Medical Exception to COVID-19 Vaccination Requirement, Part I
250509	Request for Medical Exception to COVID-19 Vaccination Requirement	Form and Instruction	Modified

ICR Details

OMB Control No: 1212-0075	ICR Reference No: 202204-1212-001
Status: Historical Active	Previous ICR Reference No: 202111-1212-001
Agency/Subagency: PBGC	Agency Tracking No:
Title: Request for Medical Exception to COVID-19 Vaccination Requirement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/06/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 04/25/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2025	36 Months From Approved	06/30/2022
Responses	2	0	5
Time Burden (Hours)	1	0	3
Cost Burden (Dollars)	0	0	0

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Abstract: Executive Order 14043 requires every Federal agency to “implement, to the extent consistent with applicable law, a program to require COVID-19 vaccination for all of its Federal employees, with exceptions only as required by law.” In following this directive, the Pension Benefit Guaranty Corporation (PBGC) issued a requirement that its employees must receive and submit proof of a COVID-19 vaccination. Also, following the requirement in Executive Order 14043 to allow exceptions to the COVID-19 vaccination requirement as required by law, PBGC is allowing an exception from the vaccination requirement for employees due to medical reasons or disabilities that would make the COVID-19 vaccine unsafe for them. To ensure that PBGC has the information to determine whether a medical exception for an employee is legally required, PBGC is providing a form to obtain information to help determine an employee’s entitlement to the exception. As of the date of this submission to OMB, the vaccination requirement issued pursuant to E.O. 14043 is currently the subject of a nationwide injunction. While that injunction remains in place, PBGC will not process requests for a medical exception from the COVID-19 vaccination requirement pursuant to E.O. 14043. PBGC will also not request the submission of any medical information related to a request for an exception from the vaccination requirement pursuant to E.O. 14043 while the injunction remains in place. But PBGC may nevertheless receive information regarding a medical exception.

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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:
	87 FR 8303	02/14/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 24349	04/25/2022
Did the Agency receive public comments on this ICR? Yes

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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 Medical Exception to COVID-19 Vaccination Requirement	Part I , Part II	Request for Medical Exception to COVID-19 Vaccination Requirement, Part I ,   Request for Medical Exception to COVID-19 Vaccination Requirement

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	2	5	0	-3	0	0
Annual Time Burden (Hours)	1	3	0	-2	0	0
Annual Cost Burden (Dollars)	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: With this renewal, only new PBGC employees, rather than current and new employees, will have cause to complete this form.

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Annual Cost to Federal Government: $0

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: 04/25/2022

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