Religious Accommodation Form

Office of the

Comptroller of the Currency ^{Employee Reference No.:}

Request for a Religious Exception

to the COVID-19 Vaccination Requirement

Employee Name Date of request

^Department Division

^{Position Supervisor} Phone Number

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. In certain circumstances, Federal law may entitle a Federal employee who has a religious objection to the COVID-19 vaccination requirement to an exception from that requirement, absent undue hardship, in which case the employee would instead comply with alternative health and safety protocols. The Federal Government is committed to respecting the important legal protections for religious liberty. The purpose of this form is to determine whether you may be eligible for an exception.

To be eligible for a possible exception, you must first establish that your refusal to be vaccinated is based upon a sincere belief that is religious in nature. A refusal to be vaccinated does not qualify for an exception if it is based upon personal preference, concerns about the possible effects of the vaccine, or political opinions.

In order to request a religious exception, please answer the following questions. The agency may ask for other information as needed to determine if you are legally entitled to an exception.

1. Please describe the nature of your objection to the COVID-19 vaccination requirement.

2. Would complying with the COVID-19 vaccination requirement substantially burden your religious exercise? If so, please explain how.

3. How long have you held the religious belief underlying your objection?

4. Please describe whether, as an adult, you have received any vaccines against any other diseases (such as a flu vaccine or a tetanus vaccine) and, if so, what vaccine you most recently received and when, to the best of your recollection.

5. If you do not have a religious objection to the use of all vaccines, please explain why your objection is limited to particular vaccines.

6. Please provide any additional information that you think may be helpful in reviewing your request.

Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge and ability, true and correct. Any intentional misrepresentation to the Federal Government may result in legal consequences, including termination or removal from Federal Service.

I declare to the best of my knowledge and ability that the foregoing is true and correct. Signature Date

Additional Information (Optional)

Privacy Act Statement

Authority: Solicitation of this information is authorized by Title VII of the Civil Rights Act of 1964, as amended; Executive Order 13164 (July 28, 2000); and Executive Order 14043 (September 09, 2021).

Purpose: The Office of the Comptroller of the Currency (OCC) is collecting the information to support its review of reasonable accommodation requests for Federal employees who indicate that they are unable to receive a COVID-19 vaccination because of a sincerely held religious belief, practice, or observance.

Additionally, the information collected will allow the OCC to track and report the processing of requests for reasonable accommodations to comply with applicable laws and regulations.

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 pursuant to certain routine uses. For example, the information may be disclosed to: a congressional office in response to an inquiry from the congressional office made at the request of the employee providing the information on this form; arbitrator or other duly authorized official engaged in investigation or settlement of a grievance, complaint or appeal filed by an employee; or to medical personnel to address a bona fide medical emergency. A complete list of the routine uses pursuant to which this information may be shared (as of November 26, 2021) can be found in the system of records notice associated with this collection of information,

Treasury .016 Reasonable Accommodations Records, available at 86 FR 59271 (October 26, 2021).

Disclosure: Providing this information is voluntary. However, failure to furnish the requested information may delay or prevent action on your reasonable accommodation request.

CC-3057, revised October 2021

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