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

Forms and Documents

Document Name	Status
Form DL1-7071A Request for a Religious Exception to the Covid-19 Vaccination Requirement Form and Instruction	New
Form DL1-7071 Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	Modified
1225-0092 SS 5.25.22 FINAL.docx Supporting Statement A	2022-05-25
SORN OASAM-38.pdf Supplementary Document	2022-05-24
OPM GOVT-10 SORN.pdf Supplementary Document	2021-11-12
DOL_CENTRAL-6 _ SORN.pdf Supplementary Document	2021-11-12

IC Document Collections

IC ID	Document Title	Status
253751	Request for a Religious Exception to the Covid-19 Vaccination Requirement Form and Instruction	New
250283	Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	Modified

ICR Details

OMB Control No: 1225-0092	ICR Reference No: 202205-1225-003
Status: Received in OIRA	Previous ICR Reference No: 202111-1225-001
Agency/Subagency: DOL/DM	Agency Tracking No:
Title: Request for a Medical or Religious Exception or Delay to the COVID-19 Vaccination Requirement
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/26/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2022
Responses	270	250
Time Burden (Hours)	48	42
Cost Burden (Dollars)	0	0

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Abstract: In compliance with Section 2 of Executive Order 14043, this information collection is used by the Department 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.”

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
   US Code: 29 USC 791 Name of Law: The Rehabilitation Act of 1973
   US Code: 42 USC 2000e - 2000e17 (Title VII) Name of Law: Civil Rights Act of 1964
  

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 13004	03/08/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 32061	05/26/2022
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination Requirement	DL1-7071	Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement
Request for a Religious Exception to the Covid-19 Vaccination Requirement	DL1-7071A	Request for a Religious Exception to the Covid-19 Vaccination Requirement

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ICR Summary 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	270	250	0	20	0	0
Annual Time Burden (Hours)	48	42	0	6	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The Department is proposing to add the form "Request for a Religious Exception to the Covid-19 Vaccination Requirement" to make it available to student volunteers, who are members of the public under the PRA. The Department estimates that 10 student volunteers may use the form and it will take 15 minutes to complete. The Department has also added respondents and time burden for the "Request for a Medical Exception to the COVID-19 Vaccination Requirement" to make the form available for student volunteers. The Department has added an additional 10 respondents and estimate it will take 15 minutes (divided between the student volunteer and the doctor) to complete the entire 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: 05/26/2022

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