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:
202205-1225-003
Status:
Historical Inactive
Previous ICR Reference No:
202111-1225-001
Agency/Subagency:
DOL/DM
Agency Tracking No:
Title:
Request for a Medical or Religious Exception or Delay to the COVID-19 Vaccination Requirement
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Withdrawn and continue
Conclusion Date:
08/18/2025
Retrieve Notice of Action (NOA)
Date Received in OIRA:
05/26/2022
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
05/31/2022
36 Months From Approved
08/31/2025
Responses
250
0
250
Time Burden (Hours)
42
0
42
Cost Burden (Dollars)
0
0
0
Abstract:
In compliance with Section 2 of Executive Order 14043, this information collection is used by the Department 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.”
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
US Code:
42 USC 2000e - 2000e17 (Title VII)
Name of Law: Civil Rights Act of 1964
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 13004
03/08/2022
30-day Notice:
Federal Register Citation:
Citation Date:
87 FR 32061
05/26/2022
Did the Agency receive public comments on this ICR?
Yes
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
DL1-7071
Request for a Medical Exception or Delay to the COVID-19 Vaccination Requirement
Request for a Religious Exception to the Covid-19 Vaccination Requirement
DL1-7071A
Request for a Religious Exception to the Covid-19 Vaccination Requirement
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:
The Department is proposing to add the form "Request for a Religious Exception to the Covid-19 Vaccination Requirement" to make it available to student volunteers, who are members of the public under the PRA. The Department estimates that 10 student volunteers may use the form and it will take 15 minutes to complete. The Department has also added respondents and time burden for the "Request for a Medical Exception to the COVID-19 Vaccination Requirement" to make the form available for student volunteers. The Department has added an additional 10 respondents and estimate it will take 15 minutes (divided between the student volunteer and the doctor) to complete the entire form.
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:
05/26/2022
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