COVID-19 Vaccination Requests for Waiver

Forms and Documents

Document Name	Status
Form DS-5159 REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction	Modified
Form DS-5158 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction	Modified
Legal Authorities 1405-0246.docx Supplementary Document	2022-06-24
30 Day supporting statement - COVID Vacc Requests for Waiver.docx Supporting Statement A	2022-06-24
Emergency PRA Letter - Signed.pdf Supplementary Document	2021-12-15

IC Document Collections

IC ID	Document Title	Status
250799	REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction	Modified
250798	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT Form and Instruction	Modified

ICR Details

OMB Control No: 1405-0246	ICR Reference No: 202206-1405-004
Status: Received in OIRA	Previous ICR Reference No: 202112-1405-009
Agency/Subagency: STATE/AFA	Agency Tracking No:
Title: COVID-19 Vaccination Requests for Waiver
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 06/24/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2022
Responses	100	100
Time Burden (Hours)	1	1
Cost Burden (Dollars)	0	0

---

Abstract: Per guidance from the Safer Federal Workforce Task Force, an agency may be required to provide a reasonable accommodation to employees or prospective employees who communicate to the agency that they are not vaccinated against COVID-19 because of a medical reason or disability, or because of a sincerely held religious belief, practice, or observance.

---

Authorizing Statute(s): EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11706	04/13/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 11768	06/24/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT	DS-5158	REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINATION REQUIREMENT
REQUEST FOR A RELIGIOUS ACCOMMODATION TO THE COVID-19 VACCINATION REQUIREMENT	DS-5159	Request for a Religious Accomodation to the COVID-19 Vaccination Requirement

---

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	100	100	0	0	0	0
Annual Time Burden (Hours)	1	1	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $6,260

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.     No

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

---

Common Form ICR:  No

---

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: 06/24/2022

---