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Federal forms, ICRs, and supporting documents

Information Collection Request

Request for Medical Exception to COVID-19 Vaccination Requirement

ICR 202204-1212-001 · OMB 1212-0075 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form Part I Request for Medical Exception to COVID-19 Vaccination Requirement Form and Instruction Modified Missing upstream
Vaccine Requirement Exemption ICR Supporting Statement 2022.03.docx Supporting Statement A Uploaded 2022-04-25 Repair queued
IC Document Collections
IC IDCollectionTypeStatusForm
250509 Request for Medical Exception to COVID-19 Vaccination Requirement Form and Instruction Modified
ICR Details
1212-0075 202204-1212-001
Received in OIRA 202111-1212-001
PBGC
Request for Medical Exception to COVID-19 Vaccination Requirement
Revision of a currently approved collection   No
Regular 04/25/2022
  Requested Previously Approved
36 Months From Approved 05/31/2022
2 5
1 3
0 0
Executive Order 14043 requires every Federal agency to “implement, to the extent consistent with applicable law, a program to require COVID-19 vaccination for all of its Federal employees, with exceptions only as required by law.” In following this directive, the Pension Benefit Guaranty Corporation (PBGC) issued a requirement that its employees must receive and submit proof of a COVID-19 vaccination. Also, following the requirement in Executive Order 14043 to allow exceptions to the COVID-19 vaccination requirement as required by law, PBGC is allowing an exception from the vaccination requirement for employees due to medical reasons or disabilities that would make the COVID-19 vaccine unsafe for them. To ensure that PBGC has the information to determine whether a medical exception for an employee is legally required, PBGC is providing a form to obtain information to help determine an employee’s entitlement to the exception. As of the date of this submission to OMB, the vaccination requirement issued pursuant to E.O. 14043 is currently the subject of a nationwide injunction. While that injunction remains in place, PBGC will not process requests for a medical exception from the COVID-19 vaccination requirement pursuant to E.O. 14043. PBGC will also not request the submission of any medical information related to a request for an exception from the vaccination requirement pursuant to E.O. 14043 while the injunction remains in place. But PBGC may nevertheless receive information regarding a medical exception.
None
None
Not associated with rulemaking
  87 FR 8303 02/14/2022
87 FR 24349 04/25/2022
Yes
  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 2 5 0 -3 0 0
Annual Time Burden (Hours) 1 3 0 -2 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes
Miscellaneous Actions
With this renewal, only new PBGC employees, rather than current and new employees, will have cause to complete this form.
$0
No
    Yes
    Yes
No
No
No
Yes
Melissa Rifkin 202 326-4400 [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.
04/25/2022