Form FCC Form 5643 FCC Form 5643 REQUEST FOR A MEDICAL EXCEPTION TO THE COVID-19 VACCINAT

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FCC Form 5643

OMB Control No. 3060-1295 Estimated
Time Per Response: 0.5 Hours
December 2021

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. Employees may seek a legal exception to the
vaccination requirement due to a disability, using the form below. The Federal Communications
Commission (FCC) 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
FCC is 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 must 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 misrepresentation to the Federal Government may result in
legal consequences, including 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 complete form (Parts 1 and 2) to
Kenneth Heredia, the FCC’s Reasonable Accommodations Coordinator, at:
Kenneth.Heredia@fcc.gov.
FCC NOTICE FOR INDIVIDUALS REQUIRED BY THE PRIVACY ACT AND THE PAPERWORK REDUCTION ACT
Authority: The Rehabilitation Act of 1973, as amended, 29 U.S.C. § 791; Executive Order 13164,
Requiring Federal Agencies to Establish Procedures to Facilitate the Provision of Reasonable
Accommodation, 65 Fed. Reg. 46,563 (Jul 28, 2000); and Equal Employment Opportunity Commission’s
Policy Guidance on Executive Order 13164: Establishing Procedures to Facilitate the Provision of
Reasonable Accommodation, Directives Transmittal Number 915.003, October 20, 2000.
Purpose: The principal purpose for collecting this information is to permit the FCC to assess whether
individuals are entitled to a reasonable accommodation. Additionally, this information is being collected
and maintained by the FCC to record and track requests for reasonable accommodation by individuals
with disabilities, their provision, and the disposition of such requests. Information collected in
connection with a request for reasonable accommodation is confidential and may be shared with FCC
officials or contractors only when those other individuals need to know the information to make
determinations on a reasonable accommodation request or to assist the Reasonable Accommodations
Coordinator in making such a determination.
Routine Uses: The records and information in the records may be used pursuant to the Routine Uses for
the system found in the System of Records Notice FCC/OWD-1, Reasonable Accommodation Requests.
Effect of Disclosure: The provision of information is voluntary; however, if you do not provide this
information, the FCC may not provide an accommodation, and you may not receive important
information.
We have estimated that your response to this collection of information will take an average of 30
minutes or 0.5 hours. Our estimate includes the time to read the instructions, look through existing

records, gather and maintain required data, and actually complete and review the form or response. If
you have any comments on this estimate, or on how we can improve the collection and reduce the
burden it causes you, please write the Federal Communications Commission, Office of Managing
Director, AMD PERM, Washington, DC 20554, Paperwork Reduction Act Project (3060-1295). We will
also accept your PRA comments via the Internet if you send an e-mail to PRA@fcc.gov.
Please DO NOT SEND COMPLETED [SURVEYS, APPLICATION FORMS, ETC] TO THIS ADDRESS. You are not
required to respond to a collection of information sponsored by the Federal government, and the
government may not conduct or sponsor this collection, unless it displays a currently valid OMB control
number and/or we fail to provide you with this notice. This collection has been assigned an OMB control
number of 3060-1295.
THIS NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13,
OCTOBER 1, 1995, 44 U.S.C. SECTION 3507.

Part 1

To Be Completed by the Employee

Employee Name

Date of Request

Bureau/Office

Division

Position

Supervisor

Phone Number

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 correctto the best of my knowledge and ability.
By signing this form, I authorize FCC officials to contact the medical professional I have listed in my
request and to collect further information about my medical condition as it may pertain to my
request. I understand that it may be necessary to reveal to others my identity and medical
information regarding my request to FCC officials.
I also understand that any information collected to process my request will be considered by the FCC
when making the decision to approve or disapprove my request and will become a part of my record
of request for an exception. This documentation will not become a part of my personnel file.
If you have questions about completing this form, please contact the FCC’s Reasonable
AccommodationCoordinator at Kenneth.Heredia@fcc.gov (by email) or 202-418-7896 (by
phone).
Employee Signature
Print Name

Date

Part 2 To be Completed by the Employee's Medical Provider
Employee Name
Medical Certification for COVID-19 Vaccine Exception
Dear Medical Provider:
The Federal Communications Commission (FCC) 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 to the requirement for COVID-19 vaccination or a delay because of a
temporary condition or medical circumstance. Please complete this form to assist the FCC in its reasonable
accommodation process. If you have questions about completing this form, please contact the FCC’s
Reasonable Accommodation Coordinator at Kenneth.Heredia@fcc.gov (by email) or 202-418-7896 (by
phone).
Please provide at least the following information, where applicable:
1. The applicable contraindication or precaution for COVID-19 vaccination, and for each

contraindication orprecaution, indicate: (a) whether it is recognized by the CDC pursuant to its
guidance; and (b) whether itis 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 suchthat 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