Medical Exception to COVID Vaccination-Supporting Statement-11-4-2021

REQUEST FOR A MEDICAL EXCEPTION TO THE
COVID-19 VACCINATION REQUIREMENT
Supporting Statement
1. Necessity for Collecting the Information
On September 9, 2021, President Biden issued Executive Order 14,043,1 which 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 template form provided by the Safer Federal Workforce
Task Force. Part one of the form, which is not subject to clearance under the Paperwork Reduction
Act (“PRA”), provides that the individual employee would seek a medical exception to the
requirement for COVID-19 vaccination or a delay because of a temporary condition or medical
circumstance. Part two of the form, which is to be completed by the employee’s medical provider,
is subject to clearance approval from the Office of Management and Budget under the PRA. The
FTC needs information requested on part two of the form from the medical provider to effectively
evaluate the employee’s reasonable accommodation request.
2. Use of the Information
The Federal Trade Commission needs the information from the employee’s medical
provider in order to effectively evaluate the employee’s request for a medical exception.
3. Consideration to Use Improved Information Technology to Reduce Burden
Responses from the employee’s medical provider to part two of the form can be returned
electronically or via paper to the employee. The employee will then upload this with their request
for a medical exception. Responses will be collected via submission by the employee through a
cloud-based ServiceNow platform that links to the appropriate FTC review official through email
notification. This provides a secure and efficient means for respondents to transmit the required
information to the FTC.

Officially Executive Order 14,043, “Requiring Coronavirus Disease 2019 Vaccination for Federal
Employees” (Sept. 9, 2021).

1

2

4. Efforts to Identify Duplication/Availability of Similar Information
The information to be collected is not duplicated elsewhere. The information also would
not be requested by another federal agency since each agency is responsible for collecting the
data as it relates to their employees.
5. Efforts to Minimize Burden on Small Businesses
A portion of the respondents will be small entities. However, the questionnaire itself is very
minimal and should only take up to 10 minutes per participant.
6. Consequences of Conducting Collection Less Frequently
Each collection from a medical provider relates directly to a request for a medical exception
from an individual employee. Any collection less frequent than that would significantly impair the
FTC’s ability to effectively evaluate a request for a medical exception.
7. Circumstances Requiring Collection Inconsistent with Guidelines
This collection of information is consistent with the guidelines contained in 5 CFR 1320.5.
8. Consultation Outside the Agency
Special circumstances exist that require an emergency clearance pursuant to 5 CFR
1320.13(a), therefore no notice has been published in the Federal Register. Executive Order 14,043
directed the Safer Federal Workforce Task Force to issue guidance within 7 days of the date of this
order (Sept. 9, 2021) on implementation by federal agencies covered by the order. The Task Force
thereafter directed that Federal employees must be fully vaccinated by November 22, 2021, other
than in limited circumstances where the law requires an exception.
Thus, the collection of information is needed prior to the expiration of time periods
ordinarily required by the PRA statute and implementing rules and is essential to the mission of the

3

FTC. 5 CFR 1320.13(a)(1)(i)-(ii). Additionally, public harm is reasonably likely to result if normal
clearance procedures are followed. 5 CFR 1320.13(a)(2)(i). This information is being collected and
maintained to promote the safety of Federal buildings and the Federal workforce consistent with the
above-referenced authorities, 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.
9. Payments or Gifts to Respondents
Not applicable.
10. & 11.

Assurances of Confidentiality and Matters of a Sensitive Nature

Part two of the form solicits information relating to whether an individual federal
employee’s condition and medical circumstances qualify that individual for an exception to the
COVID-19 vaccination mandate. This is sensitive health information subject to additional
protections. This information will be collected, maintained, and secured pursuant to the applicable
Privacy Act systems for General Personnel Records (FTC-II-1) and when applicable, Employee
Health Care Records (FTC-II-10) and Employee Medical File System of Records (OPM/GOVT10). The authorized routine uses are set out within those systems.
12. Burden Estimate
The estimated burden of collecting this information is as follows:
35 respondents
x 1 per respondent
= 35 total annual responses
x (10/60 hours per average respondent)
= 5.83 annual hours for respondents
x $104/hour for personnel2

This is derived from the hourly mean rate for family medicine physicians in the Bureau of Labor Statistics,
Occupational Employment and Wages – May 2020, March 31, 2021, Table 1,
https://www.bls.gov/news.release/pdf/ocwage.pdf.

2

4

$606 annual labor cost for respondents.
13. Estimated Capital or Other Non-Labor Costs
The Agencies believe that there are no current start-up costs or other capital costs associated
with the information collection.
14. Estimated Cost to the Federal Government
The Agencies estimate that a representative year’s cost of collecting the information will be
minimal.
15. Program Changes or Adjustments
This is a new information collection.
16. Statistical Use of Information
The proposed collection does not employ statistical methods.
17. Display of Expiration Date for OMB Approval
Not applicable.
18. Exceptions to the Certification for Paperwork Reduction Act Submissions
Not applicable. No exceptions are being requested on the certification statement.