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Federal forms, ICRs, and supporting documents

Information Collection Request

Medical Exception Request to the COVID-19 Vaccination Requirement

ICR 202201-3079-001 · OMB 3079-0001 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form FMSHRC-09-001 FMSHRC Medical Exception Request Form Form and Instruction Modified Repair queued
2022-4-28 FMSHRC Transmittal Letter to OIRA.pdf Supplementary Document Uploaded 2022-04-28 Repair queued
2021-11-22 FMSRHC Transmittal Letter to OIRA .docx Supplementary Document Uploaded 2021-11-23 Repair queued
2021-11-22 FMSRHC Transmittal Letter to OIRA .docx Supplementary Document Uploaded 2021-11-22 Repair queued
2022-4-28 FMSHRC Transmittal Letter to OIRA.pdf Supporting Statement A Uploaded 2022-04-28 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
250495 FMSHRC Medical Exception Request Form Form and Instruction Modified
ICR Details
3079-0001 202201-3079-001
Received in OIRA 202111-3079-001
FMSHRC
Medical Exception Request to the COVID-19 Vaccination Requirement
Extension without change of a currently approved collection   No
Regular 04/28/2022
  Requested Previously Approved
36 Months From Approved 05/31/2022
6 6
24 24
600 600
In order to ensure the health and safety of the Federal workforce and the efficiency of the civil service, full Coronavirus Disease 2019 Vaccination was made mandatory for all Federal employees, with exceptions only required by law, under Executive Order 14043. Subsequently, a federal court imposed an injunction preventing the federal government from enforcing mandatory vaccination. However, because the Information Collection form for seeking a Reasonable Accommodation to the vaccination had already been approved by OMB for FMSHRC use prior to the court injunction, FMSHRC is seeking to renew the ICR in the event that the injunction is lifted or further COVID-19 vaccinations are required during the period that an approved ICR Renewal would be in effect. In the event that vaccinations may be required, requests for “medical accommodation” or “medical exceptions” will be treated as requests for 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 per guidance provided by the Safer Federal Workforce Task Force.
EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
   US Code: 29 USC 791 Name of Law: Rehabilitation Act Section 501
  
EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
Not associated with rulemaking
  87 FR 17 01/26/2022
87 FR 19513 04/04/2022
No
1
IC Title Form No. Form Name
FMSHRC Medical Exception Request Form FMSHRC-09-001, FMSHRC-09-002 FMSHRC Medical Exception Request Form ,   Medical Exception Request to the Vaccination Requirement
  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 6 6 0 0 0 0
Annual Time Burden (Hours) 24 24 0 0 0 0
Annual Cost Burden (Dollars) 600 600 0 0 0 0
No
No
$999
No
    Yes
    Yes
No
No
No
Yes
Kimberly Burch 202 494-9913 [email protected]
  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/28/2022