Emergency Request Letter for OMB

CUI//SP-HLTH/SP-PERS/SP-PRVCY
(CUI when filled in)

REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
Government-wide policy requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated against
COVID-19, with exceptions only as required by law. Employees may seek a legal exception to the vaccination
requirement due to a disability, using the form below. The agency may also ask for other information, as needed.
Requests for “medical accommodation” or “medical exceptions” will be treated as requests for a disability
accommodation and evaluated and decided under applicable Rehabilitation Act standards for reasonable
accommodation absent undue hardship to the agency. An employee may also request a delay for complying with
the vaccination requirement based on certain medical considerations that may not justify an exception under the
Rehabilitation Act. Safer Federal Workforce Task Force guidance on medical considerations that may warrant a
delay is available here. The agency will be required to keep confidential any medical information provided, subject
to the applicable Rehabilitation Act standards. Employees who receive an exception or a delay from the vaccination
requirement would instead comply with alternative health and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best of your
knowledge and ability. Any intentional misrepresentation to the Federal Government may result in legal
consequences, including termination or removal from Federal Service.
To request a medical exception or delay from the COVID-19 vaccination requirement using this form:
1.
2.
3.
4.

You should complete Part 1 of this form.
Your medical provider must complete Part 2 of this form.
When both are completed, you must submit the form to your supervisor.
If completed via email, then the completed form must be submitted through encrypted email.

Privacy Act Statement
Authority: The Privacy Act of 1974, as amended (5 U.S.C. 552a), requires that you be given certain information about
this form. The authority for this Request for a Medical Exception to the COVID-19 Vaccination Requirement form is
derived from Executive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sept. 9,
2021), which requires the U.S. Department of Commerce (the Department) to implement, to the extent consistent
with applicable law and subject to the availability of appropriations, a program to require COVID-19 vaccination for all
of its Federal employees, with exceptions only as required by law. In particular, the Department may be required to
provide a reasonable accommodation to employees who communicate to the Department that they are not
vaccinated against COVID-19 because of a disability. The authority for this form is also derived from the Rehabilitation
Act of 1973, as amended, which 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,
Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable Accommodation (July 28,
2000).
Purposes/Routine Uses: The information on this form may be used by the Department to help determine whether the
employee is entitled to an accommodation. The supervisor will maintain a record of all accommodation requests,
including this form, which will be utilized to determine the efficacy and consistency of the reasonable accommodation
process and be compiled for reports to the Equal Employment Opportunity Commission (EEOC); these records are
subject to periodic review by the EEOC, or the Director, Office of Civil Rights, at their request, to ensure compliance. In
addition, the information collected on this form may be used for Routine Uses set forth in System of Records Notice
COMMERCE/DEPT-18, Employees Personnel Files Not Covered by Notices of Other Agencies, except as prohibited by
the Rehabilitation Act of 1973 or as otherwise prohibited by law. The information collected on this form must be kept
in files separate from the individual's personnel file and treated as a confidential medical record, except that:
1

CUI//SP-HLTH/SP-PERS/SP-PRVCY
(CUI when filled in)

• supervisors and managers who need to know may be told about necessary restrictions on the work or
duties of the employee and about the necessary accommodation(s);
• first aid and safety personnel may be told if the disability might require emergency treatment or evacuation
assistance;
• government officials may be given information necessary to investigate the agency's compliance with the
Rehabilitation Act or other applicable laws;
• the information may in certain circumstances be disclosed to workers' compensation offices;
• and agency EEO officials may be given the information to maintain records and evaluate and report on the
agency's performance in processing reasonable accommodation requests.
Disclosure: Completion of this form is voluntary; however, accommodation may not be given to a qualified individual
without this written information.
The public reporting burden for this collection of information is estimated to average 10 minutes per response,
including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data
needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing the burden, to the
Department of Commerce, PRA Headquarters, at PRAcomments@doc.gov. Respondents should be aware that
notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a
collection of information if it does not display a currently valid OMB control number.

2

CUI//SP-HLTH/SP-PERS/SP-PRVCY
(CUI when filled in)

Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Bureau/Operating Unit

Division/Office

Position

Supervisor

Phone Number

Medical or Disability Exception Request
I am requesting a medical exception to the requirement for COVID-19 vaccination or a delay because
of a temporary condition or medical circumstance. I declare that the information I have provided is
true and correct to the best of my knowledge and ability.
Employee Signature

Print Name

Date

3

CUI//SP-HLTH/SP-PERS/SP-PRVCY
(CUI when filled in)

Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
U.S. Department of Commerce (the Department) requires its employees to be fully vaccinated
against COVID-19 pursuant to Executive Order of the President of the United States. The individual
named above is seeking a medical exception to the requirement for COVID-19 vaccination or a delay
because of a temporary condition or medical circumstance. Please complete this form to assist the
Department in its reasonable accommodation process. If you have questions about completing this
form, please contact the supervisor at
Please describe the employee's medical condition in the box below, providing at least the following
information, where applicable:

1. The applicable contraindication or precaution for COVID-19 vaccination, and for each

contraindication or precaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether it is listed in the package insert or Emergency Use Authorization fact
sheet for each of the COVID-19 vaccines authorized or approved for use in the United States;
2. A statement that the individual’s condition and medical circumstances relating to the individual
are such that COVID-19 vaccination is not considered safe, indicating the specific nature of the
medical condition or circumstances that contraindicate immunization with a COVID-19 vaccine
or might increase the risk for a serious adverse reaction; and
3. The specific medical condition that currently prevents the employee from being vaccinated or
any other medical condition that would limit the employee from receiving any COVID-19 vaccine.
Description of the medical condition for which the employee listed above should be
excepted from complying with a COVID-19 vaccination requirement:

The condition described above is:

temporary

long-term

If this is a temporary condition or medical circumstance, when it is expected to end or expire (allowing
for COVID-19 vaccination to begin after the date you provided):
Medical Provider Name/Title

Medical Provider Signature

Date

4