Form EIB 21-03 EIB 21-03 Request for a Medical Exception to COVID-19 Vaccination

EIB 21-03 | PENDING | Modified November 2021

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. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, you must submit the form to your agency’s
designated point of contact.

Privacy Act Statement

Authority: We are authorized to collect the information requested on this form
pursuant to 29 U.S.C. § 1302; 44 U.S.C. § 3101; 5 U.S.C. § 301; 29 U.S.C. § 701 et seq.;
29 U.S.C. §791; 42 U.S.C. § 12101 et seq.; 42 U.S.C. § 2000e et seq.; 42 U.S.C. §
2000bb; 42 U.S.C. Ch. 21, 126; 29 CFR Parts 1605, 1614, 1630; Executive Order
13164 (July 26, 2000); and Executive Order 13548 (July 26, 2010).
Purpose: This information is being collected and maintained to allow applicants,
current, and former employees and other individuals who participate in EXIM
programs or activities with physical and/or mental disabilities, and/or sincerely held
religious beliefs, practices, or observances who request and/or receive reasonable
accommodation by EXIM; (2) to track and report the processing of requests for
reasonable accommodation EXIM-wide to comply with applicable law and
regulations; and (3) to maintain the confidentiality of medical and/or religious
information submitted by or on behalf of applicants or employees requesting
reasonable accommodation.
Routine Uses: While the information requested on this form 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:
physicians or other medical professionals or religious or spiritual advisors or
institutions to provide them with or obtain from them the necessary
documentation and/or certification for reasonable accommodation; another
Federal agency or commission with responsibility for labor or employment relations
or other issues, including equal employment opportunity and reasonable
accommodation issues, when that agency or commission has jurisdiction over
reasonable accommodation issues; the Office of Management and Budget (OMB),
Department of Labor (DOL), Office of Personnel Management (OPM), Equal
Employment Opportunity Commission (EEOC), or Office of Special Counsel (OSC) to
obtain advice regarding statutory, regulatory, policy, and other requirements
related to reasonable accommodation; appropriate third-parties contracted by the
Agency to facilitate mediation or other dispute resolution procedures or programs;
or to a Federal agency or entity authorized to procure assistive technologies and
services in response to a request for reasonable accommodation.

Part 1 – To Be Completed by the Employee
Employee Name

Date of Request

Office

Division/ Unit

Position Title

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

Part 2 – To Be Completed by the Employee’s Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
Export Import Bank of the United States (EXIM) 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 EXIM in its reasonable accommodation process. If you have
questions about completing this form, please contact EXIM’s reasonable accommodation
coordinator at David.Campos@exim.gov or (202) 565-3321.
Please provide 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 factsheet 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 aCOVID-19 vaccine or might increase the risk for a serious adverse
reaction; and
3. Any other medical condition that would limit the employee from receiving any COVID19 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