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:
1225-0092
ICR Reference No:
202111-1225-001
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
DOL/DM
Agency Tracking No:
Title:
Request for a Medical Exception 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:
11/18/2021
OIRA Conclusion Action:
Approved without change
Conclusion Date:
11/16/2021
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/15/2021
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2022
6 Months From Approved
Responses
250
0
0
Time Burden (Hours)
42
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
This information is being requested to promote the federal workforce, the safety of federal buildings, and others on site at agency facilities or those interacting with the public consistent with the COVID-19 Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task Force and guidance from the CDC. To request a medical exemption from the COVID-19 vaccination requirement, an employee must complete Section I of the medical exemption form, and their medical provider must complete Sections II and III.
Emergency Justfication:
This information is essential to implement agencies’ health and safety measures included within recent Centers for Disease Control and Prevention and Safer Federal Workforce Task Force Guidance. The Department of Labor (DOL) has an urgent need to collect information for individuals applying for medical exemption to the COVID-19 Mandatory Vaccinations and this medical exemption form is necessary for DOL to determine legal exemptions to the vaccine requirement under the Rehabilitation Act and Americans with Disabilities Act. Applying regular Paperwork Reduction Act (PRA) clearance procedures is likely to cause harm because of the threat of COVID-19 exposure and transmission.
Authorizing Statute(s):
EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
US Code:
29 USC 791
Name of Law: The Rehabilitation Act of 1973
Citations for New Statutory Requirements:
EO: EO 14043 Name/Subject of EO: Requiring Coronavirus Disease 2019 Vaccination for Federal Employees
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 Exception to the COVID-19 Vaccination Requirement
DL1-7071
Request for a Medical Exception 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
250
0
250
0
0
0
Annual Time Burden (Hours)
42
0
42
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:
This is a new information collection.
Annual Cost to Federal Government:
$0
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:
Mara Blumenthal 202 693-8538 blumenthal.mara@dol.gov
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:
11/15/2021
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