Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form

ICR 202110-0690-001

OMB: 0690-0036

Federal Form Document

Forms and Documents
IC Document Collections
ICR Details
202110-0690-001
Received in OIRA
DOC/OS
Request for a Medical Exemption to the COVID-19 Vaccination Requirement Form
New collection (Request for a new OMB Control Number)   No
Emergency 10/27/2021
10/26/2021
  Requested Previously Approved
6 Months From Approved
1,000 0
167 0
0 0

Consistent with Executive Order 14043, of September 9, 2021, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, and included within the Safer Federal Workforce Task Force Guidance mandating all Federal employees be vaccinated by November 22, 2021, the Department of Commerce (DOC) has established specific safety protocols for individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who are not fully vaccinated against COVID-19 by November 22, 2021, or who choose not to provide this information will be required to comply with applicable OMB. OPM and DOC guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements. DOC employees may request an exemption on the basis of a medical condition or circumstance. Exemptions will be granted in limited circumstances and only where legally required. The Medical Exemption Form will be provided directly to the individuals who are requesting a medical exemption.
DOC is seeking approval of the form, “Request for a Medical Exemption Form to the COVID-19 Vaccination Requirement,” which will be completed by employees who seek a medical exemption. DOC seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing. The Form will be used by DOC staff and provided to employees to ensure they submit adequate information to support the exemption request. This form will also ensure the information collected is consistent among the components and minimize the need to seek additional evidence. Rendered decisions should be in accordance with guidelines established by the Safer Federal Workforce Task Force Guidance.

EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  
None

Not associated with rulemaking

No

1
IC Title Form No. Form Name
DOC Request for Medical Exemption Form DOC Request for a Medical Exemption Form

  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 1,000 0 0 1,000 0 0
Annual Time Burden (Hours) 167 0 0 167 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new collection.

$247,432
No
    Yes
    Yes
No
No
No
Yes
Zachary Schwartz 202 577-1769 zschwartz@doc.gov

  No

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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
10/26/2021


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