FMSHRC-09-001 FMSHRC Medical Exception Request Form

Medical Exception Request to the Vaccination Requirement
In order to ensure the health and safety of the Federal workforce and the efficiency of the civil service,
full Coronavirus Disease 2019 Vaccination is now mandatory for all Federal employees, with exceptions
only required by law, under the new Executive Order 14043.
Employees may seek a legal exception to the vaccination requirement due to a disability or medical
reason. 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.
The purpose of this form is to determine whether you may be eligible for an exception. The agency
may also ask for other information as needed.
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.

How to Use this Form
Part 1. Employee Information

You must complete all fillable forms and electronically sign the document.

Part 2. Medical Provider
Information

Your medical provider must complete all fillable forms and electronically
sign the document.
When both are completed, submit the form to our Reasonable
Accommodations Coordinator, Michael Chirico, at mchirico@fmshrc.gov.

Privacy Act Statement
Authority and
Purpose:

Collection of the requested information is authorized by Section 501 of the Rehabilitation Act, 29
U.S.C. § 791. The information you furnish will be used for the purpose of facilitating your request.
The authority for the system of records notice (SORN) associated with this collection of
information is FMSHRC-09, Medical Exception Request to the Vaccination Requirement, 86 Fed.
Reg. 66301 (November 22, 2021).

Routine Use:

Additionally, the information may be used to disclose information to: appropriate Federal, state
or local agencies when relevant to civil, criminal or regulatory investigations or prosecutions when
necessary to adjudicate a claim for benefits; a Federal agency in connection with a decision in
hiring, retention or the granting of a security clearance. It may also be used in an administrative
or judicial proceeding affecting an employee's personnel rights and in any criminal prosecutions
for willfully making false or fraudulent statements in violation of U.S.C. § 1001. Additional uses
may include disclosure to the Department of Justice for the purpose of litigating any civil,
administrative, or judicial proceeding where the United States, the IRS, or its employees (in their
official capacities or where the government has decided to represent them) are parties. It may
also be used in response to subpoena from a third party provided that (1) IRS is a party in
interest, (2) the records are relevant and necessary to the litigation, and (3) not otherwise
privileged. This information may be provided to professional associations, such as state bar
disciplinary authorities, for use in connection with their administration of standards of conduct.
Further, it may be disclosed to contractors when necessary to perform work associated with
reasonable accommodation and to those Federal agencies that oversee property and
procurement matters.

Consequence of Failure to Provide Information:

Furnishing the requested information is required to establish that you have a covered disability,
the functional limitations of your disability, and the need for reasonable accommodation. Failure
to fully complete the form or refusal to provide the requested documentation may lead to a
breakdown in the reasonable accommodation process and could result in a determination that
you are not entitled to reasonable accommodation.

Medical Exception Request Form – FMSHRC-09-001 – Federal Employees – Rev11222021

Page 1 of 3

Paperwork Reduction Act
We have estimated that each response to this collection of information will take 1-2 hours. Our estimate includes
the time to read the instructions, look through existing records, contact a medical provider to fill out a portion of
the form, and actually complete and review the form or response.
If you have any comments on this estimate, or on how we can improve the collection and reduce the burden it
causes you, please write the Federal Mine Safety and Health Review Commission, 1331 Pennsylvania Avenue, NW,
Suite 520N, Washington, DC 20004-1710. We will also accept your comments via the Internet if you send them to
PrivacyAct@fmshrc.gov. Please DO NOT SEND COMPLETED REQUESTS TO THIS ADDRESS.
Remember - you are not required to respond to a collection of information sponsored by the Federal government,
and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control
number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of
__________.
THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, P.L. 104-13, OCTOBER 1,
1995, 44 U.S.C. 3507

Assurance of Confidentiality
Medical information obtained in connection with the reasonable accommodation process must be kept confidential
and may only be disclosed to individuals who have a verifiable need to know of the medical information. All medical
information, including information about functional limitations and reasonable accommodation needs that the
Commission obtains in connection with a request for reasonable accommodation, must be kept by the
Administrative Office in a Medical Folder, separate from the individual's Official Personnel or Applicant Folder. The
same requirements apply to electronic files. A Commission employee who obtains or relies on such medical
information is strictly bound by these confidentiality requirements.

Part 1. Employee Information
Employee Name:

Date of Request:

Work Email:

Work Phone Number:

Office Location:

Department:

Position:

Supervisor:

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.

Medical Provider Name and Title:
Employee Signature:

Today’s Date:

Medical Exception Request Form – FMSHRC-09-001 – Federal Employees – Rev11222021

Page 2 of 3

Part 2. Employee’s Medical Provider Information
Employee Name:
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider: The Federal Mine Safety & Health Review Commission (FMSHRC) 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 FMSHRC in its reasonable accommodation process. If you have questions about
completing this form, please contact FMSHRC’s Reasonable Accommodation Coordinator, Michael Chirico, at
mchirico@fmshrc.gov or (202) 434-9909.
Please provide at least the following information, where applicable:
1.

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;

2.

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; 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 and Title:
Medical Provider Signature:

Today’s Date:

Medical Exception Request Form – FMSHRC-09-001 – Federal Employees – Rev11222021

Page 3 of 3