Transportation Security Officer Medical Questionnaire

Forms and Documents

Document	Type	Status	Availability
Vital Signs FE form	Form and Instruction	New	Available
Vision FE form	Form and Instruction	New	Available
TB FE form	Form and Instruction	New	Available
Seizure FE form	Form and Instruction	New	Available
Respiratory FE form	Form and Instruction	New	Available
Palmar Sensation FE form	Form and Instruction	New	Available
Orthopedic FE form	Form and Instruction	New	Available
Mental Health FE form	Form and Instruction	New	Available
Implanted Medical Device FE form	Form and Instruction	New	Available
HIV FE form	Form and Instruction	New	Available
Hernia FE form	Form and Instruction	New	Available
Hepatitus FE form	Form and Instruction	New	Available
Hearing FE form	Form and Instruction	New	Available
General FE form	Form and Instruction	New	Repair queued
Drug Alcohol Use FE form	Form and Instruction	New	Available
Diabetes FE form	Form and Instruction	New	Available
Cardiac Surgery FE form	Form and Instruction	New	Available
Cardiac FE form	Form and Instruction	New	Available
Cancer FE form	Form and Instruction	New	Available
Transportation Security Officer Medical Questionnaire	Form and Instruction	Modified	Available
44 USC 44935.doc	Supplementary Document	Uploaded 2006-09-15	Available
MQ Revision 30DY (8-24-06).pdf	Supplementary Document	Uploaded 2006-08-25	Available
MQ_CHS revised 60dy (4-19-06).pdf	Supplementary Document	Uploaded 2006-08-25	Available
83i Med Q_83i_SuppStmt (FINAL 8-21-06).doc	Supporting Statement A	Uploaded 2006-08-25	Repair queued

IC Document Collections

IC ID	Collection	Type	Status	Form
44985	Vital Signs FE form	Form and Instruction	New
44984	Vision FE form	Form and Instruction	New
44983	TB FE form	Form and Instruction	New
44982	Seizure FE form	Form and Instruction	New
44981	Respiratory FE form	Form and Instruction	New
44980	Palmar Sensation FE form	Form and Instruction	New
44979	Orthopedic FE form	Form and Instruction	New
44978	Mental Health FE form	Form and Instruction	New
44977	Implanted Medical Device FE form	Form and Instruction	New
44976	HIV FE form	Form and Instruction	New
44975	Hernia FE form	Form and Instruction	New
44974	Hepatitus FE form	Form and Instruction	New
44973	Hearing FE form	Form and Instruction	New
44972	General FE form	Form and Instruction	New
44971	Drug Alcohol Use FE form	Form and Instruction	New
44970	Diabetes FE form	Form and Instruction	New
44969	Cardiac Surgery FE form	Form and Instruction	New
44968	Cardiac FE form	Form and Instruction	New
44935	Cancer FE form	Form and Instruction	New
20961	Transportation Security Officer Medical Questionnaire	Form and Instruction	Modified

ICR Details

OMB Control No: 1652-0032	ICR Reference No: 200608-1652-003
Status: Historical Active	Previous ICR Reference No: 200503-1652-001
Agency/Subagency: DHS/TSA	Agency Tracking No:
Title: Transportation Security Officer Medical Questionnaire
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/04/2007
	Date Received in OIRA: 09/25/2006
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2010	36 Months From Approved	09/30/2008
Responses	68,438	0	38,100
Time Burden (Hours)	22,813	0	11,430
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information will assist the agency in ensuring that candidates under employment consideration for Transportation Security Officer (TSO) positions meet the qualification standards to successfully perform the functions of the position. The information will be collected from applicants for TSO positions to evaluate a candidate's candidate’s current and past medical history including visual and aural acuity, physical coordination, and motor skills.

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Authorizing Statute(s): US Code: 49 USC 44935 Name of Law: null
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 20118	04/19/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 50080	08/24/2006
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 20

IC Title	Form No.	Form Name
Drug Alcohol Use FE form	n/a	Drug Alcohol Use Further Evaluation
Transportation Security Officer Medical Questionnaire	N/A	Transportation Security Officer Medical Questionnaire
Hepatitus FE form	n/a	Hepatitus Further Evaluation
Hernia FE form	n/a	Hernia further evaluation
Cardiac Surgery FE form	n/a	Cardiac Surgery further evaluation
General FE form	n/a	General Further Evaluation
Cardiac FE form	n/a	Cardiac Further Evaluation form
Mental Health FE form	n/a	Mental Health further evaluation
Cancer FE form	n/a	Further Evaluation Form Cancer
Vision FE form	n/a	Vision further evaluation
Orthopedic FE form	n/a	Orthopedic further evaluation
HIV FE form	n/a	HIV further evaluation
Palmar Sensation FE form	n/a	Palmar Sensation further evaluation
TB FE form	n/a	TB further evaluation
Respiratory FE form	n/a	Respiratory further evaluation
Seizure FE form	n/a	Seizure further evaluation
Hearing FE form	n/a	Hearing Further Evaluation
Vital Signs FE form	n/a	Vital Signs further evaluation
Implanted Medical Device FE form	n/a	Implanted Medical Device further evaluation
Diabetes FE form	n/a	Diabetes Further Evaluation

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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	68,438	38,100	0	30,338	0	0
Annual Time Burden (Hours)	22,813	11,430	0	11,383	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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: See supporting statement. TSA added additional medical evaluation forms, which increased the respondent population and number of responses. However, we note that the hour burden reflected in chart above is not accurate; it should be 19,013, NOT 22,813. The way we are required to enter ICs divides burden up equally for all of the further evaluation forms and that is not the method we used for our calculations. This is because not all respondents need to fill out all further evaluation forms; depending on the medical conditions of applicants, some respondents may fill out 1 or 5 or none and we have no concrete way to determine the exact numbers. Thus, our supporting statement reflects our best good faith estimate.

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Annual Cost to Federal Government: $2,556,241

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 09/25/2006

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