Supporting Statement Part A -Emergency ICR COVID 19 Medical Exemption Form 10 25 2021

SUPPORTING STATEMENT

U. S. Department of Commerce

Medical Exemption Form

OMB Control No. 0690-NEW

Abstract

The purpose of this emergency request of Paperwork Reduction Act (PRA) clearance is to allow the Department of Commerce (DOC) to collect information from individuals applying for medical exemption to the COVID-19 Mandatory Vaccinations as specified in the Agency Medical Exemption Form, Part 2. Given the critical role of the collection of information to meeting our commitments as outlined in Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees and the Safer Federal Workforce Task Force guidance, the DOC cannot reasonably comply at present with the normal clearance procedures.

Justification

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

Consistent with guidance from the Centers for Disease Control and Prevention (CDC), guidance from the Safer Federal Workforce Task Force established pursuant to Executive Order 13991 of January 20, 2021, Protecting the Federal Workforce and Requiring Mask-Wearing, and Executive Order 14043 of September 9, 2021, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees, the request for this collection of information is essential to implement the Department of Commerce’s health and safety measures regarding the Federal Employee medical exemptions to the COVID-19 mandatory vaccinations. The Rehabilitation Act of 1973, as amended, requires Federal Agencies to provide reasonable accommodations to qualified employees with disabilities unless that reasonable accommodation would impose an undue hardship on the employee’s Agency. See 29 U.S.C. 791; 29 C.F.R. Part 1614; see also 20 C.F.R. Part 1630 and Executive Order 13164 of July 26, 2000, Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation. Section 2 of E.O. 14043 mandates that each agency “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.” This medical exemption form is necessary for Commerce to determine legal exemptions to the vaccine requirement under the Rehabilitation Act.

Government agencies have an urgent need to request medical exemption information with input from medical providers from federal employees. Applying regular Paperwork Reduction Act clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission (5 C.F.R § 1320.13(c)).

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

This information is being requested to promote the Federal workforce, the safety of Federal buildings, and others on site at agency facilities or those interacting with the public consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the Centers for Disease Control and Prevention. To request a medical exemption from the COVID-19 vaccination requirement, an employee must complete Part 1 of the medical exemption form and their medical provider must complete Part 2.

Specifically, this information will be used by DOC staff charged with implementing and enforcing COVID-19 workplace safety protocols 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 Bureaus and minimize the need to seek additional evidence.

DOC seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing.

Table: Information Requirements and Needs and Uses of Information Collected

Item #	Requirement	Executive Order	Regulation	Needs and Uses
1	Medical Exemption Form	14043	5 C.F.R. § 1320.13	Used by Federal employee to request medical exemption from COVID-19 Vaccine Mandates. Used by the Federal employee’s medical provider for medical certification of COVID-19 Vaccine exemption. Used by DOC staff to process the request and enforce the COVID-19 Vaccine Mandates.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also, describe any consideration of using information technology to reduce burden.

This information collection is paper-based and will require the individual responder to fill out the required fields of the form and submit the completed form to the appropriate DOC personnel. A link to this form or a PDF version may be emailed to respondents who will then print it out to complete it or complete it electronically. We will continue to explore options to use technology to reduce the burden on individuals.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Question 2

We are unaware of other sources of similar information available for use by the respondents.

5. If the collection of information impacts small businesses or other small entities, describe any methods used to minimize burden.

This information collection request has no identified impact on small businesses and organizations.

6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

Less frequent collection would inhibit DOC’s ability to meet the mandates of the Safer Federal Workforce Task Force and DOC’s specific established COVID-19 workplace safety protocols.

7. Explain any special circumstances associated with conducting this information collection.

There are no other special circumstances involved in the collection of this information.

8. If applicable, provide a copy and identify the date and page number of publications in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

DOC has requested and has been granted a waiver from the requirement to publish a notice in the Federal Register in connection with a request for emergency clearance of this information collection request.

Aside from discussions with Office of Management and Budget (OMB) personnel, and other Federal agencies, no additional consultation was conducted for this submission.

9. Explain any decision to provide any payment or gift to respondents, other than renumeration of contractors or grantees.

No gifts or payments of any kind have been provided to any individuals who are connected to this collection.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy. If the collection requires a system of records notice (SORN) or privacy impact assessment (PIA), those should be cited and described here.

This collection is covered under COMMERCE/DEPT-18, Employees Personnel Files Not Covered by Notices of Other Agencies, and has an approved privacy statement on applicable forms.

This SORN is available at: https://www.osec.doc.gov/opog/PrivacyAct/SORNs/DEPT-18.html.

Please find our medical form at the link below with the privacy act statement included: Template - Request for a Medical Exception to the Covid-19 Vaccination Requirement (commerce.gov). The Privacy Act Statement in this form references the System of Records Notice for COMMERCE/DEPT-18, Employees Personnel Files Not Covered by Notices of Other Agencies.

The Privacy Act Statement also describes and references confidentiality protections under the Rehabilitation Act of 1973, as amended.

A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.

11. Provide additional justification for any questions of a sensitive nature.

The questions included on this form are consistent with OMB’s guidance for requesting a medical exemption.

12. Provide estimates of the respondent burden hours and labor costs

Table - Estimated Annualized Respondent Burden Hours

Information Collection Instrument	Type of Respondent (e.g., Occupational Title)	# Of Respondents (a)	Annual # of Responses/ Respondent (b)	Total # of Annual Responses (c) = (a) x (b)	Burden Hours/ Response (d)	Total Annual Burden Hours (e) = (c) x (d)
Part 2	Medical Provider	1000	1	1000	10/60	166.66
Totals				1000		166.66

Table - Estimated Annualized Respondent Labor Costs

Type of Respondent/ Occupational Title	Number of Respondents	Number of Responses per Respondent	Average Burden per Response	Hourly Wage Rate*	Total Burden Costs
Medical Provider	1000	1	10/60	$55.93	$9.32
Total	--	--	--	--	$9321

* https://www.bls.gov/bls/blswage.htm

13. Provide an estimate for the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any burden costs already reflected on the burden worksheet).

There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.

14. Provide estimates of annualized cost to the Federal government.

Table – Annualized Costs to the Federal Government

Personnel	Grade/Step	Hours	Hourly Wage (dollars)	Annual Costs (dollars)
Federal Staff	Band 3/3	1.5	$73.39	$                       7,339.00
Federal Staff	Band 3/3	1.5	$73.39	$                       7,339.00
Federal Staff	ZA-IV	10	$76.50	$                   39,780.00
Federal Staff	ZA-IV	10	$81.00	$                       8,100.00
Federal Staff	GS-14 step 1	1.5	$58.71	$                       1,409.00
Federal Staff	GS-7 step 3	2	$25.12	$                   11,304.00
Federal Staff	GS-11 step 2	2	$24.34	$                     10,953.00
Federal Staff	GS-11 step 2	8	$36.02	$                    28,816.00
Federal Staff	GS-12 step 1	8	$41.78	$                     33,424.00
Federal Staff	GS-12 step 9	8	$52.93	$                    42,344.00
Federal Staff	GS-12 step 1	8	$41.78	$                    33,424.00
Federal Staff	GS-13 step 3	8	$53.00	$                 21,200.00
Printing				$ 2,000.00
Estimated Total Annual Cost to the Government				$                   247,432.00

15. Explain the reasons for any program changes or adjustments reported in ROCIS.

This is a new information collection.

16. For collections of information whose results will be published, outline plans for tabulation and publication.

DOC will not publish the results of this information collection.

However, this data will be provided to the CDC in an aggregate form. Also, the Department is required to report to OMB on the total number of employees who are fully vaccinated, partially vaccinated, requesting reasonable accommodations, or not vaccinated.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

The OMB Expiration Date will be displayed on every data collection instrument.

18. Explain each exception to the certification statement identified in “Certification for

Paperwork Reduction Act Submissions."

The agency certifies compliance with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).