Introduction
The policy statement, how requests are evaluated, the option to request a delay, confidentiality of medical information and the two steps for requesting an exception.
GSA19M
Request for a Medical Exception to the COVID-19 Vaccination Requirement
- Agency
- GSA
- Revision
- Rev. 2/2022
- Fillable fields
- 21
- Pages
- 2
- Official source
- GSA form page
- Checked
- October 20, 2026
GSA Form 19M: Request for a Medical Exception to the COVID-19 Vaccination Requirement
GSA Form 19M is the Request for a Medical Exception to the COVID-19 Vaccination Requirement. The footer reads GENERAL SERVICES ADMINISTRATION and GSA 19M (REV. 2/2022), and GSA hosts it in its forms library. GSA's page lists the authority or regulation as 5 U.S.C. § 2105 and says the form is for GSA Employee use only.
The form says 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. It says employees may use it to seek a legal exception due to a disability, or a delay based on certain medical considerations, and that requests are evaluated and decided under applicable Rehabilitation Act standards for reasonable accommodation.
The form has two parts: Part I for the employee and Part II for the employee's medical provider. You can fill it out free in your browser on this page and download the result without an account.
What's on GSA Form 19M
Part I: employee details
Employee name, date of request, GSA staff or service office, office, branch or division, position, the employee's supervisor and a telephone number.
Part I: exception request and signature
A statement requesting a medical exception or a delay because of a temporary condition or medical circumstance, and declaring the information true and correct, with signature, name and date.
Privacy Act Statement
The statutory authority, purpose and use, routine uses under GSA/HRO-1, and the consequence of not supplying the information.
Part II: medical certification
The provider gives any contraindication or precaution, whether the CDC recognizes it and whether the package insert or Emergency Use Authorization fact sheet lists it, a statement on safety, and any other limiting condition.
Part II: condition and provider signature
A description of the condition, a Temporary or Permanent box, when a temporary condition is expected to end, and the provider's name, title, signature and date.
How to complete GSA Form 19M
- 1
Complete Part I
The employee enters name, date of request, office, branch or division, position, supervisor and telephone number.
- 2
Sign the request
The employee signs and dates the Medical or Disability Exception Request. The form says signing constitutes a declaration that the information is true and correct.
- 3
Add the coordinator's details
The form says the employee provides the name and telephone number of the Local Reasonable Accommodation Coordinator in Part II.
- 4
Give Part II to the medical provider
The form says the employee's medical provider completes Part II, the Medical Certification for COVID-19 Vaccine Exception.
- 5
Provider describes the condition
The provider answers items 1 to 3, describes the condition, marks Temporary or Permanent and, if temporary, says when it is expected to end.
- 6
Provider signs and dates
The medical provider enters name and title, signs and dates Part II.
Why fill Form GSA19M on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the GSA, not a copy someone retyped
- Works on a phone, tablet or computer
Routing and what the form says
Where it goes
The form prints no address. It names the Local Reasonable Accommodation Coordinator as the contact for questions, and says the agency may ask for other information as needed.
Confidentiality
The form says the agency will be required to keep confidential any medical information provided, subject to the applicable Rehabilitation Act standards.
Privacy
The Privacy Act Statement says requesting a reasonable accommodation is a voluntary process and access is limited to individuals with a need to know, under the System of Records Notice GSA-HRO-1.
Authority
GSA's page lists 5 U.S.C. § 2105. The Privacy Act Statement lists 29 U.S.C. § 791, 42 U.S.C. § 12101, 42 U.S.C. § 2000e-16, 29 U.S.C. § 2601, 40 U.S.C. § 3173 and E.O. 13164, 13548, 14042 and 14043.
False statements
The form says any intentional misrepresentation to the Federal Government may result in legal consequences, including termination or removal from Federal Service.
Related forms
Who fills out GSA Form 19M?
GSA's page says the form is for GSA Employee use only. The form splits the work between these people.
Official sources and the blank
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Questions about Form GSA19M
Who issues GSA Form 19M?
The footer reads GENERAL SERVICES ADMINISTRATION and GSA 19M (REV. 2/2022). GSA hosts it in its forms library, and GSA's page says the form is for GSA Employee use only.
Can GSA Form 19M be used to ask for a delay?
The form says an employee may also request a delay based on certain medical considerations that may not justify an exception under the Rehabilitation Act. Part I covers an exception or a delay because of a temporary condition or medical circumstance.
Who completes Part II?
The form says the employee's medical provider completes Part II. The Local Reasonable Accommodation Coordinator's name and telephone number sit under a label that reads To be filled out by the employee.
How does the form say requests are decided?
It says 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.
Is the medical information kept confidential?
The form says the agency will be required to keep confidential any medical information provided, subject to the applicable Rehabilitation Act standards, and limits access to individuals with a need to know.
What happens if information is left out?
The Privacy Act Statement says that if an employee or applicant does not provide the necessary information, a decision-maker may deny the reasonable accommodation request.