Supporting Statement - USPSC Medical Exception Form

Title: U.S. PERSONAL SERVICES CONTRACTOR REQUEST FOR A MEDICAL EXCEPTION
TO THE COVID-19 VACCINATION REQUIREMENT
Form names and numbers: U.S. PERSONAL SERVICES CONTRACTOR REQUEST FOR A
MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
OMB Control Number: 0412-xxxx
PART A. JUSTIFICATION
1. Explain the circumstances that make the collection of information necessary.
This information is being collected and maintained to promote the safety of Federal workplaces and the
Federal workforce consistent with Executive Order 14042, Executive Order 13991, Protecting the
Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the COVID-19 Workplace Safety:
Agency Model Safety Principles established by the Safer Federal Workforce Task Force, and guidance
from Centers for Disease Control and Prevention and the Occupational Safety and Health
Administration. Government-wide policy requires all USAID Personal Services Contractors (PSCs) to
be vaccinated against COVID-19, with exceptions only as required by law. United States PSCs
(USPSCs) may seek a legal exception to the vaccination requirement due to a medical disability.
As required, USAID is implementing the federal COVID-19 vaccination mandate and is
simultaneously considering USPSCs’ requests for legally-required exceptions or delays to the
vaccination mandate. Requests for “medical accommodation,” “medical exceptions,” or “medical
delays” are treated as requests for a disability accommodation and as such must be evaluated and
decided under applicable Rehabilitation Act standards for reasonable accommodation absent undue
hardship to the agency. In order to determine an appropriate and effective accommodation, USAID
proposes to collect medical information necessary for case processing using the form under review.
In determining whether documentation is necessary to support a request for reasonable accommodation
and whether an individual has a disability within the meaning of the Rehabilitation Act, the USAID is
guided by the principles in the ADA Amendments Act of 2008. Specifically, the ADA Amendments Act
directs that the definition of “disability” be construed broadly and that the determination of whether an
individual has a “disability” generally should not require extensive analysis. Supporting medical
documentation must describe the impairment; the nature, severity, and duration of the impairment; the
activity or activities that the impairment limits; the extent to which the impairment limits the individual's
ability to perform the activity or activities; and/or the nexus between the impairment and the requested
accommodation. The proposed form follows these guidelines and requests applicant’s obtain the
following from their medical provider:
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. Any other medical condition that would limit the contractor from receiving any COVID-19 vaccine.

The collection of this medical information is necessary to sufficiently evaluate and make determinations
on medical exception or delay requests to the COVID-19 vaccine requirement. Please note, the proposed
USAID form for information collection is based directly on the template form provided by the Safer
Federal Workforce Task Force and contains no substantive material changes from the template.

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.
In accordance with Executive Order 14042 (Ensuring Adequate COVID Safety Protocols
for Federal Contractors), USAID is implementing the federal vaccine mandate for its
USPSC workforce and reviewing contractors requests for medical exceptions or delays to
the requirement because of a temporary condition or medical circumstance. For USAID
USPSCs who believe they are not able to get vaccinated because of a qualifying medical
condition and submit an exception request, USAID must evaluate the medical conditions
on a case-by-case basis. The Office of Civil Rights and Diversity (OCRD), Reasonable
Accommodation Manager (RAM) may request medical information to identify an individual’s
functional limitations or to determine whether the applicable condition meets the definition of a
“disability” pursuant to the Rehabilitation Act, as amended, except when the disability and
need for accommodation are reasonably obvious (e.g., blindness) or the individual has already
provided sufficient, up-to-date medical information documenting the propriety of the
accommodation.
The standards and process below apply to all requestors (e.g., Civil Service and Foreign
Service employees, Direct-Hire applicants or PSC offerors, and other staff to the extent
applicable). The RAM may also request medical information to determine an appropriate and
effective accommodation. In determining whether documentation is necessary to support a
request for reasonable accommodation and whether an individual has a disability within the
meaning of the Rehabilitation Act, the RAM is guided by the principles in the ADA
Amendments Act of 2008. Specifically, the ADA Amendments Act directs that the definition of
“disability” be construed broadly and that the determination of whether an individual has a
“disability” generally should not require extensive analysis. Supporting medical documentation
must describe the impairment; the nature, severity, and duration of the impairment; the activity
or activities that the impairment limits; the extent to which the impairment limits the
individual's ability to perform the activity or activities; and/or the nexus between the
impairment and the requested accommodation.
For reasonable accommodations pursuant to internal USAID policy (ADS 111), only the RAM
may request supporting medical documentation of the individual's disability, limitations, and
restrictions, and the RAM may only request relevant information. The RAM requires that an
appropriate, licensed professional, such as a doctor, social worker, or rehabilitation counselor,
provide the medical documentation concerning the disability. When the requestor provides
sufficient information that can substantiate the existence of a disability, functional limitations,
workplace limitations, or barriers and the need for a particular reasonable accommodation,
additional medical information may not be required. The RAM may make further inquiries
where such information is not clear or if it does not make sufficiently clear whether a possible
alternative accommodation will be effective.

When an individual has already submitted medical documentation in connection with a
previous request for accommodation, the individual must immediately inform the RAM. The
RAM must determine whether additional medical information is needed for the new request.
When the RAM determines that the initial information provided by the health professional or
the requestor is insufficient to a) determine whether the individual has a “disability”; b) identify
the limitations; or c) determine that a particular accommodation is needed, the RAM must
explain what additional information is required. The RAM may require that the individual’s
healthcare professional provide additional information that: Describes the nature, severity, and
duration of the individual's impairment; Describes the activity that the impairment limits, and
the extent of the limitation on the individual’s ability to perform necessary activities;
Substantiates why the requested accommodation is needed and how the reasonable
accommodation will assist the individual to perform the essential functions of the job, or
equally enjoy a benefit or privilege of the workplace; or Invites the medical provider to offer
or opine on alternative accommodations that may be effective under the circumstances.
Supporting medical documentation may also be deemed insufficient if: The health care
professional does not have the expertise to give an opinion about the medical condition and the
limitations imposed by it; The information does not specify the functional limitations currently
due to the disability; or Other factors indicate that the information provided is not credible.
The RAM may provide information to the healthcare professional concerning the nature of the
position, essential functions of the position, and other relevant information. If the medical
information is insufficient for the reasons stated above, the RAM can request the U.S.
Department of Health and Human Services’ Program Support review the medical information
at the Agency's expense, if such review is job-related and consistent with business necessity.
The individual requesting the accommodation can also sign a limited release allowing the RAM
to communicate directly with the health care professional. Failure of requesting individual to
provide appropriate documentation or to cooperate with the Agency may result in the delay of
or inability to grant the reasonable accommodation request.
Disability-Related Inquiries and Medical Exams:
https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-actand-other-eeo-laws#A
Specifically for the medical exception on vaccine requirements - the RAM will consult with the
respective groups as needed, as outlined in Primary Responsibilities of the ADS-111 (Human
Capital Talent Management’s Employee Labor Relations and the Office of General Counsel), for
additional guidance to grant or deny the exception request.

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.
The form is in electronic fillable PDF format. Users have the option to fill out the form
electronically or to print, fill out the information on paper, and scan the paper document to an
electronic system for submission. All forms must be submitted electronically via email to the Office
of Civil Rights and Diversity. Given the U.S. Agency for International Development’s continued
mandatory telework status, in-person paper submissions or mailing to Agency headquarters are not
possible. Moreover, electronic submission is an improved form of information technology that
reduces the burden on users.

The form is a part of an internal process to process contractor’s exception or delay to the
COVID-19 vaccine requirement requests and as such, is not available to the general public.
Additionally, due to the nature of the collected material, results of the information collected will not
be made available to the public.
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 item 2
above.
As outlined in item 2 above, the Office of Civil Rights and Diversity (OCRD), Reasonable
Accommodation Manager (RAM) may request medical information to identify an
individual’s functional limitations or to determine whether the applicable condition meets the
definition of a “disability” pursuant to the Rehabilitation Act, as amended, except when the
disability and need for accommodation are reasonably obvious (e.g., blindness) or the
individual has already provided sufficient, up-to-date medical information documenting the
propriety of the accommodation. Given the COVID-19 vaccine requirement was mandated
on September 9, 2021, the OCRD does not already have up-to-date medical information on
contractors related to the COVID-19 vaccine that is sufficient to move forward with an
accommodation, without additional information requests.
5. If the collection of information impacts small businesses or other small entities, describe
any methods used to minimize burden.
The collection of information may impact medical providers’ offices who qualify as small
businesses because the form requires medical information to be submitted directly from
respondents’ medical providers. In order to minimize the burden on these entities, the form can be
completed and submitted electronically. Additionally, the form only requires the medical provider to
include statements on the respondents’ applicable medical conditions, it does not require additional
medical documentation.
The collection should not impact other small businesses or other small entities.
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 the burden.
If the medical information is not collected, contractors requests for an exception or
delay to the COVID-19 vaccination requirement cannot be processed. The Agency
would be unable to do its due diligence when evaluating requests. If requests are
not processed and individuals who should qualify are not able to receive an
exception or delay, illegal discrimination may inadvertently occur as the Agency
enforces the federal vaccination mandate, pursuant to Executive Order 14042.
Additionally, the proposed form allows for the uniform collection of information
predetermined to be necessary for case processing. Uniform collection is critical to
ensure all cases are evaluated and processed in the same way. Please note, the
proposed form is built directly off of the template provided by the Safer Federal

Workforce Task Force and has no substantive material changes from the template.
Collection is only required once and as such, cannot be conducted less frequently.
7. Special Circumstances
There are no special circumstances that would cause the information collected to be
conducted in a manner:
● requiring respondents to report information to the agency more often than quarterly;
● requiring respondents to prepare a written response to a collection of information in
fewer than 30 days after receipt of it;
● requiring respondents to submit more than an original and two copies of any
document;
● requiring respondents to retain records, other than health, medical, government
contract, grant-in-aid, or tax records, for more than 3 years.
● in connection with a statistical survey, that is not designed to produce valid and
reliable results that can be generalized to the universe of study;
● requiring the use of a statistical data classification that has not been reviewed and
approved by OMB;
● that includes a pledge of confidentiality that is not supported by authority
established in statute or regulation, that is not supported by disclosure and data
security policies that are consistent with the pledge, or which unnecessarily impedes
sharing of data with other agencies for compatible confidential use; or
● requiring respondents to submit proprietary trade secrets, or other confidential information
unless the agency can demonstrate that it has instituted procedures to protect the
information's confidentiality to the extent permitted by law. Please see item 10 for
information on how the agency has instituted procedures to protect respondents’ information.
8. If applicable, provide a copy and identify the date and page number of publication 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.
In the Justification Statement included in this emergency approval request, USAID is requesting
OIRA approval to not publish a Federal Register notice in association with this form.
9. Explain any decision to provide any payment or gift to respondents, other than
remuneration of contractors or grantees.
Payment or gifts will not be provided to respondents.
10. Describe any assurance of confidentiality provided to respondents and the basis for the
assurance in statute, regulation, or agency policy.
The Privacy Act (5 U.S.C. 552a) applies to this collection and is used as a statutory authority for
confidentiality. The authorities for the system of records notices (SORNs) associated with this
collection of information are USAID-32, Reasonable Accommodation Records, 81 FR 70085 (October
11, 2016) and USAID-34, Personal Services Contracts Records, 80 FR 11391 (March 3, 2015).
While the information requested is intended to be used primarily for internal purposes, in certain

circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work
environment; to adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing
examiners to the extent necessary to carry out their authorized duties regarding Federal employment; to
contractors, grantees, or volunteers as necessary to perform their duties for the Federal Government; to
other agencies, courts, and persons as necessary and relevant in the course of litigation, and as
necessary and in accordance with requirements for law enforcement; or to a person authorized to act on
your behalf. A complete list of the routine uses can be found in the SORN associated with this
collection of information, USAID-32, Reasonable Accommodation Records, 81 FR 70085 (October 11,
2016) and USAID-34, Personal Services Contracts Records, 80 FR 11391 (March 3, 2015).

11. Provide additional justification for any questions of a sensitive nature, such as sexual
behavior and attitudes, religious beliefs, and other matters that are commonly considered
private.
As outlined in Section E. (Pandemic-Related Harassment Due to National Origin, Race, or Other
Protected Characteristics) of the U.S. Equal Employment Opportunity Commission’s What You
Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws , it is
against the federal Equal Employment Opportunity laws to harass or otherwise discriminate against
coworkers based on race, national origin, color, sex, religion, age (40 or over), disability, or genetic
information. For contractors requesting medical exceptions or delays to the federal COVID-19
vaccine requirement, it is necessary to request contractors medical condition information in order to
assess eligibility for the requested exceptions or delays and prevent disability-related harassment.
Medical information obtained will be used by USAID’s Office of Civil Rights and Diversity
(OCRD), Reasonable Accommodation Manager (RAM) to help determine whether the contractor is
entitled to an exception or delay.
The form includes the following information, informing people from whom the information is
requested on why the information is being requested, how it will be used, and consequences for not
providing the information:
Purpose: This information is being collected and maintained to promote the safety of Federal
workplaces and the Federal workforce consistent with the above-referenced authorities, Executive
Order 13991, Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the
COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal
Workforce Task Force, and guidance from Centers for Disease Control and Prevention and the
Occupational Safety and Health Administration.
Routine Uses: While the information requested is intended to be used primarily for internal
purposes, in certain circumstances it may be necessary to disclose this information externally, for
example to disclose information to: a Federal, State, or local agency to the extent necessary to
comply with laws governing reporting of communicable disease or other laws concerning health and
safety in the work environment; to adjudicative bodies, arbitrators, and hearing examiners to the
extent necessary to carry out their authorized duties regarding covered Federal contractors; to other
agencies, courts, and persons as necessary and relevant in the course of litigation, and as necessary
and in accordance with requirements for law enforcement; or to a person authorized to act on your
behalf. A complete list of the routine uses can be found in the SORN associated with this collection

of information, USAID-32, Reasonable Accommodation Records, 81 FR 70085 (October 11, 2016)
and USAID-34, Personal Services Contracts Records, 80 FR 11391 (March 3, 2015).
Consequence of Failure to Provide Information: Providing this information is mandatory. Unless
granted a legally required exception, all covered Federal contractors are required to be vaccinated
against COVID-19 and to provide documentation concerning their vaccination status to their
employing agency. Unless you have been granted a legally required exception, failure to provide
this information may result in the termination of your contract or other remedies.

12. Provide estimates of the hour burden of the collection of information.

The hour burden is not expected to vary widely. The amount of requested information from
each individual is the same.
Form
Name

U.S.
PERSON
AL
SERVICE
S
CONTRA
CTOR
REQUES
T FOR A
MEDICA
L
EXCEPTI
ON TO
THE
COVID-1
9
VACCIN
ATION
REQUIR
EMENT

Form
Number

No. of
Respon
dents

40

No. of
Respons
es per
Respon
dent
One

Average.
Burden
per
Response
(in hours)
.75 hour

Total
Annual
Burden
(in
hours)
30 hour

0412-xxx
x

13. Provide an estimate for the total annual cost burden to respondents or record-keepers
resulting from the collection of information.

A total capital and start-up cost component (annualized over its expected useful life): none.
A total operation and maintenance and purchase of services component: none.
Contractors may have a copay related to the doctor’s visit. The average copay is $35. If so, the
annual cost burden is $1,400.
14. Provide estimates of annualized costs to the Federal Government.
There will be no costs beyond the normal labor costs for staff.
15. Explain the reasons for any program changes or adjustments reported on the burden
worksheet.
This is a new program.
16. For collections of information whose results will be published, outline plans for tabulation
and publication. Address any complex analytical techniques that will be used. Provide the
time schedule for the entire project, including beginning and ending dates of the collection of
information, completion of report, publication dates, and other actions.
Results will not be published.
17. If you are seeking approval to not display the expiration date for OMB approval of the
information collection, explain the reasons that display would be inappropriate.
We are not seeking approval to not display the expiration date for OMB approval of the
information collection.
18. Explain each exception to the topics of the certification statement identified in
Certification for Paperwork Reduction Act Submissions.
There are no requested exceptions to the topics of the certification statement identified in the
Certification for Paperwork Reduction Act Submissions section of OMB form 83-I.
PART B. COLLECTIONS OF INFORMATION EMPLOYING STATISTICAL
METHODS
The collection does not employ statistical methods.