SUPPORTING
STATEMENT FOR
PAPERWORK
REDUCTION ACT SUBMISSION
COVID-19 Vaccination – Requests for Waiver
OMB Number 1405-0246
A. JUSTIFICATION
Why is this collection necessary and what are the legal statutes that allow this?
In accordance with 5 U.S.C. §§ 3301, 3302, and Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, and subsequent guidance from the Safer Federal Workforce Task Force, all federal employees and individuals who start their government service after November 22, 2021, must be fully vaccinated prior to their start date, except in limited circumstances where an accommodation is legally required. Per guidance from the Safer Federal Workforce Task Force, an agency may be required to provide a reasonable accommodation to employees or prospective employees who communicate to the agency that they are not vaccinated against COVID-19 because of a medical reason or disability, or because of a sincerely held religious belief, practice, or observance. Determining whether an exception is legally required includes consideration of factors such as the basis for the claim; the nature of the employee’s job responsibilities; and the reasonably foreseeable effects on the agency’s operations, including protecting other agency employees and the public from COVID-19. The collection of this information is necessary in order to make these determinations. This information collection covers two Department of State forms:
Request for a Disability or Medical Exception to the COVID-19 Vaccination Requirement (“Medical Exception”); and
Request for a Religious Accommodation to the COVID-19 Vaccination Requirement (“Religious Exception”).
What business purpose is the information gathered going to be used for?
The purpose of collecting this information is to provide an avenue for individuals to request an exception to the vaccination requirement as a medical/disability or religious accommodation, and to determine whether the request for an exception to Executive Order 14043 is valid and can be accommodated.
Is this collection able to be completed electronically (e.g., through a website or application)?
For prospective employees, both forms are PDFs that must be printed, completed, signed, and e-mailed to points of contact. The Medical Exception form has two parts: Part 2 of the form must be completed by a medical professional before the entire document is scanned and e-mailed.
Does this collection duplicate any other collection of information?
The information is not maintained elsewhere or otherwise available.
Describe any impacts on small business.
The information collection does not involve small business or other small entities.
What are the consequences if this collection is not done?
If the collection were not done, there would be no ability to determine legally required religious and/or medical exceptions to the requirement that all employees and prospective employees receive COVID-19 vaccinations under Executive Order 14043.
No special circumstances exist.
The Department is publishing a Federal Register notice and is soliciting comments for 60 days.
No payment or gift is provided to respondents.
Describe assurances of privacy/confidentiality.
The System of Records Notices State-31 (Human Resources Records), OPM/GOVT-10 (Employee Medical File System of Records), and State-24 (Medical Records) apply to this collection.
The forms contain questions of a sensitive nature, covering the respondent’s religious beliefs and medical information. A respondent claiming a medical or religious exception must provide enough information for the Department to evaluate their request for an exception.
Describe the hour time burden and the hour cost burden on the respondent needed to complete this collection
The Department estimates that this information collection will be used by approximately 100 respondents annually and estimates that the average time to complete the Religious Exception form will be 0.75 hour, and the Medical Exception form will be 0.25 hour, plus medical provider review for an additional 0.50 hour. The average amount of time to complete the forms is 0.75 of an hour. Therefore, the hour burden of this collection is estimated to be 75 hours.
Describe the monetary burden to respondents (out of pocket costs) needed to complete this collection.
There is no cost to complete either form, beyond printing and signing the forms.
Based on similar requests received from current employees, the Department estimates that 80 percent of the forms (80) will be Religious Exception, and 20 percent (20) will be Medical Exception.
Department employees who are at the GS-13, GS-11, and GS 9 level will review the estimated 20 medical exception request forms. It will take approximately 60 minutes per form. The average pay for these employees is $45 per hour. Therefore, the estimated total cost to review the forms is $900.
Department employees who are at the GS-15, GS-14, GS-13, and FS-02 level will process and review the estimated 80 religious exception request forms. It will take approximately 60 minutes per form. The average pay for these employees is $67 per hour. Therefore, the estimated total cost to review the forms is $5360.
Explain any changes/adjustments to this collection since the previous submission
There have been no changes to the forms since the emergency approval of this information collection.
Specify if the data gathered by this collection will be published.
The data will not be published.
If applicable, explain the reason(s) for seeking approval to not display the OMB expiration date.
The Department will display the expiration date for OMB approval on the information collection.
Explain any exceptions to the OMB certification statement.
The Department is not requesting any exception to the certification statement.
B. COLLECTION OF INFORMATION EMPLOYING STATISTICAL METHODS
This collection does not employ statistical methods.
Drafted: GTM/RAWG – Amy Nicodemus: 202-344-7660
Cleared:
L/M: Alice Kottmyer
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | "%username%" |
| File Modified | 0000-00-00 |
| File Created | 2022-06-27 |