Request for a Medical Exception to the COVID-19 Vaccination Requirement

Forms and Documents

Document Name	Status
Form 1 Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	New
Emergency Justification Letter.pdf Supplementary Document	2021-12-21
Supporting Statement Part A 12 120 2021 FINAL.docx Supporting Statement A	2021-12-21

IC Document Collections

IC ID	Document Title	Status
250869	Request for a Medical Exception to the COVID-19 Vaccination Requirement Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202112-3202-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: OSHRC	Agency Tracking No:
Title: Request for a Medical Exception to the COVID-19 Vaccination Requirement
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 01/13/2022
Date Submitted to OIRA: 01/12/2022

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	3	0
Time Burden (Hours)	9	0
Cost Burden (Dollars)	0	0

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Abstract: The collection of information is necessary for the Review Commission to consider any employee request for a medical exception to the COVID-19 vaccination requirement. The information is collected from the requester's medical provider. Only agency employees are covered by the form. This is a new collection of information. The information collected will be used to determine whether an employee is entitled under section 501 of the Rehabilitation Act of 1973, 29 U.S.C. 791, to a medical exception to the vaccine mandate for federal employees set forth in E.O. 14043.

Emergency Justfication: Emergency clearance of our agency's medical exception form is necessary to allow our agency to timely process any medical exception requests to the COVID-19 vaccination requirement. This is essential to our agency's mission, in that disruption to the work of any employee requesting an exception would, in tum, undermine the agency's ability to meet our mission and function at an optimal level.

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Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: EO on Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (9/9/2021)
   US Code: 29 USC 791 Name of Law: Rehabilitation Act of 1973
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Request for a Medical Exception to the COVID-19 Vaccination Requirement	1	Request for a Medical Exception to the COVID-19 Vaccination Requirement

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3	0	0	3	0	0
Annual Time Burden (Hours)	9	0	0	9	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: There has been no change in burden.

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Annual Cost to Federal Government: $1,608

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/12/2022

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