Fillable U.S. DIRECT HIRE REQUEST FOR A MEDICAL EXCEPTION (United States Agency for International Development)

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U.S. DIRECT HIRE REQUEST FOR A MEDICAL EXCEPTION (United States Agency for International Development)

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U.S. DIRECT HIRE REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19
VACCINATION REQUIREMENT
Government-wide policy requires all Federal employees, as defined in 5 U.S.C. § 2105, to be vaccinated
against COVID-19, with exceptions only as required by law. Em
ployees may seek a legal exception to the
vaccination requirement due to a disability, using the form below. The agency may also ask for other
information, as needed. Requests for “medical accommodation” or “medical exceptions” will be treated as
requests for a 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. Safer Federal Workforce Task Force
guidance on medical considerations that may warrant a delay is available
here. The agency will be
required to keep confidential any medical information provided, subject to the applicable Rehabilitation
Act standards. Employees who receive an exception or a delay from the vaccination requirement would
instead comply with alternative health and safety protocols.
Signing this form constitutes a declaration that the information you provide is true and correct to the best
of your knowledge and ability. Any intentional m
isrepresentation to the Federal Government may result in
legal and administrative consequences, including discipline, termination or removal from Federal Service.
To request a medical exception or delay from the COVID-19 vaccination requirement using this form:
1. You must complete Part 1 of this form.
2. Your medical provider must complete Part 2 of this form.
3. When both are completed, you must submit the form to your agency’s designated point of contact.
Privacy Act Statement
Authority: Pursuant to 5 U.S.C. chapters 1
1 and 79, and in discharging the functions directed under
E
xecutive Order 14043, Requiring Coronavirus Disease 2019 Vaccination for Federal Employees (Sept. 9,
2021), we are authorized to collect this information. The authority for the system of records notice
(SORN) associated with this collection of information, USAID-32, Reasonable Accommodation Records,
81 FR 70085 (October 11, 2016). Providing this information is mandatory, and we are authorized to
impose penalties for failure to provide the information pursuant to applicable Federal personnel laws and
regulations.
Purpose: This information is being collected and maintained to promote the safety of Federal workplaces
and the Federal workforce consistent with the above-referenced authorities, Executive Order 13991,
Protecting the Federal Workforce and Requiring Mask-Wearing (Jan. 20, 2021), the COVID-19
Workplace Safety: Agency Model Safety Principles established by the Safer Federal Workforce Task
Force, and guidance from Centers for Disease Control and Prevention and the Occupational Safety and
Health Administration.
OMB No: 0412-0612
Expiration Date: 04/30/2022
Page 1 of 5 Pages
Routine Uses: While the information requested is intended to be used primarily for internal purposes, in
certain circumstances it may be necessary to disclose this information externally, for example to disclose
information to: a Federal, State, or local agency to the extent necessary to comply with laws governing
reporting of communicable disease or other laws concerning health and safety in the work environment;
to adjudicative bodies (e.g., the Merit System Protection Board), arbitrators, and hearing examiners to the
extent necessary to carry out their authorized duties regarding Federal employment; to contractors,
grantees, or volunteers as necessary to perform their duties for the Federal Government; to other agencies,
courts, and persons as necessary and relevant in the course of litigation, and as necessary and in
accordance with requirements for law enforcement; or to a person authorized to act on your behalf. A
complete list of the routine uses can be found in the SORN associated with this collection of information,
USAID-32, Reasonable Accommodation Records, 81 FR 70085 (October 11, 2016).
Consequence of Failure to Provide Information: Providing this information is mandatory. Unless
granted a legally required exception, all covered Federal employees are required to be vaccinated against
COVID-19 and to provide documentation concerning their vaccination status to their employing agency.
Unless you have been granted a legally required exception, failure to provide this information may subject
you to disciplinary action, including and up to removal from Federal service.
Part 1 – To Be Completed by the Employee
Employee Name Date of Request
Mission/Bureau/Independent Office/Division Hiring Mechanism
Position Phone Number Supervisor
Medical or Disability Exception Request
I am requesting a medical exception to the requirement for COVID-19 vaccination or a delay because
of a temporary condition or medical circumstance. I declare that the information I have provided is true
and correct to the best of my knowledge and ability.
Employee Signature
Print Name Date
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Part 2 – To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The U.S. Agency for International Development (USAID) requires its employees to be fully vaccinated
against COVID-19 pursuant to Executive Order of the President of the United States. The individual
named above is seeking a medical exception or a delay to the requirement for COVID-19 vaccination
because of a temporary condition or medical circumstance. Please complete this form to assist USAID
in its reasonable accommodation process. If you have questions about completing this form, please
contact USAID’s reasonable accommodation coordinator at ReasonableAccommodations@usaid.gov.
Please provide at least the following information, where applicable:
1. The applicable contraindication or precaution for COVID-19 vaccination, and for each
contraindication or precaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether it is listed in the package insert or Emergency Use Authorization
fact sheet for each of the COVID-19 vaccines authorized or approved for use in the United
States;
2. A statement that the individual’s condition and medical circumstances relating to the individual
are such that COVID-19 vaccination is not considered safe, indicating the specific nature of the
medical condition or circumstances that contraindicate immunization with a COVID-19
vaccine or might increase the risk for a serious adverse reaction; and
3. Any other medical condition that would limit the employee from receiving any COVID-19
vaccine.
Description of the medical condition for which the employee listed above should be excepted from
complying with a COVID-19 vaccination requirement:
The condition described above is:
Temporary
Long-Term
If this is a temporary condition or medical circumstance, when it is expected to end or expire (allowing
for COVID-19 vaccination to begin after the date you provided):
Medical Provider Name/Title
Medical Provider Signature
Date
Paperwork Reduction Act Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a
person be subject to a penalty for failure to comply with a collection of information subject to the
requirements of the Paperwork Reduction Act unless that collection of information displays a currently
valid OMB Control Number. The OMB Control Number for this information collection is 0412-0612
.
Public reporting for this collection of information is estimated to be approximately 45
minutes per
response.
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U.S. DIRECT HIRE REQUEST FOR A MEDICAL EXCEPTION (United States Agency for International Development)

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Completed 23 November 2021

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