Form Unknown Request for a Medical Exception to the COVID-19 Vaccinat

TEMPLATE
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.

Include Privacy Act Statement Here

Part 1 – To Be Completed by the Employee
[Agencies should modify these fields as needed for purposes of identifying the employee.]
Employee Name
Date of Request

Department
Position

Division
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:
[AGENCY NAME] 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 [AGENCY NAME] in its reasonable accommodation
process. If you have questions about completing this form, please contact [AGENCY NAME]’s
reasonable accommodation coordinator at [EMAIL AND PHONE HERE].
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 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 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