View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0704-0619
ICR Reference No:
202110-0704-007
Status:
Active
Previous ICR Reference No:
Agency/Subagency:
DOD/DODDEP
Agency Tracking No:
0704-DMEF
Title:
Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Emergency
Approval Requested By:
10/20/2021
OIRA Conclusion Action:
Approved without change
Conclusion Date:
10/20/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/19/2021
Terms of Clearance:
This collection is approved for 6 months only. Should this collection need to be used for longer than 6 months, DOD must publish a 60 and 30 day notice.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
04/30/2022
6 Months From Approved
Responses
180,000
0
0
Time Burden (Hours)
15,000
0
0
Cost Burden (Dollars)
405,000
0
0
Abstract:
Consistent with Executive Order 14043, of September 9, 2021, “Requiring Coronavirus Disease 2019 Vaccination for Federal Employees”, and included within the Safer Federal Workforce Task Force Guidance mandating all Federal employees be vaccinated by November 22, 2021, the Department of Defense (DoD) has established specific safety protocols for individuals fully vaccinated and not fully vaccinated against coronavirus disease 2019 (COVID-19). Individuals who are not fully vaccinated against COVID-19 by November 22, 2021, or who choose not to provide this information will be required to comply with applicable OMB. OPM and DoD guidance for individuals not fully vaccinated against COVID-19, including wearing masks regardless of the transmission rate in a given area, physical distancing, regular screening testing, and adhering to applicable travel requirements. DoD civilian employees may request an exemption on the basis of a medical condition or circumstance. Exemptions will be granted in limited circumstances and only where legally required. The DD Form 3176 will be provided directly by the individuals who is requesting a medical exemption.
Emergency Justfication:
DoD is seeking approval of DD Form 3176, “Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement,” which will be completed by employees who seek a medical exemption. DoD seeks OMB’s approval to process the form as emergency clearance requests in accordance with 5 C.F.R. § 1320.13, Emergency Processing. The DD Form 3176 will be used by DoD staff and provided to employees to ensure they submit adequate information to support the exemption request. This form will also ensure the information collected is consistent among the components and minimize the need to seek additional evidence. Rendered decisions should be in accordance with guidelines established by the Safer Federal Workforce Task Force Guidance.
Authorizing Statute(s):
None
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
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement
DD 3176
Request for a Medical Exemption or Delay to the COVID-19 Vaccination Requirement
ICR Summary of Burden
Total Approved
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
180,000
0
0
180,000
0
0
Annual Time Burden (Hours)
15,000
0
0
15,000
0
0
Annual Cost Burden (Dollars)
405,000
0
0
405,000
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
This is a new collection with a new associated burden.
Annual Cost to Federal Government:
$5,152,600
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.
Yes
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
Agency Contact:
Brandon Kim 703 344-6832 brandon.h.kim8.ctr@mail.mil
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:
10/19/2021
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