Transportation Security Officer Medical Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Vital Signs further evaluation	Form and Instruction	Removed	Available
Vision further evaluation	Form and Instruction	Removed	Available
TB further evaluation	Form and Instruction	Removed	Available
Seizure further evaluation	Form and Instruction	Removed	Available
Respiratory further evaluation	Form and Instruction	Removed	Available
Palmar Sensation further evaluation	Form and Instruction	Removed	Available
Orthopedic further evaluation	Form and Instruction	Removed	Available
Mental Health further evaluation	Form and Instruction	Removed	Available
Implanted Medical Device further evaluation	Form and Instruction	Removed	Available
HIV further evaluation	Form and Instruction	Removed	Available
Hernia further evaluation	Form and Instruction	Removed	Available
Hepatitus Further Evaluation	Form and Instruction	Removed	Available
Hearing Further Evaluation	Form and Instruction	Removed	Available
General Further Evaluation	Form and Instruction	Removed	Available
Drug Alcohol Use Further Evaluation	Form and Instruction	Removed	Available
Diabetes Further Evaluation	Form and Instruction	Removed	Available
Cardiac Surgery further evaluation	Form and Instruction	Removed	Available
Cardiac Further Evaluation form	Form and Instruction	Removed	Available
Further Evaluation Form Cancer	Form and Instruction	Removed	Available
Transportation Security Officer Medical Questionnaire	Form and Instruction	Removed	Available
Form TSA Form 1130B-19 Vital Signs Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-18 Vision Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-17 TB Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-16 Seizure Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-15 Respiratory Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-14 Palmar Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-13 Orhopedic	Form and Instruction	New	Available
Form TSA Form 1130B-12 Mental Health Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-11 Pacemaker Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-10 HIV Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-9 Hernia Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-8 Hepatitis Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-7 Hearing Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-6 General Medical Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-5 Drug Use Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-4 Diabetes Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-3 Cardiac Surgery Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-2 Cardiac Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130B-1 Cancer Further Evaluation	Form and Instruction	New	Available
Form TSA Form 1130A-1 TSO Medical Questionnaire	Form and Instruction	New	Available
RELEASE - TSA_Form_1130A-3_FINAL_01.08.10.docx	Supplementary Document	Uploaded 2010-01-22	Available
NOTIFICATION - TSA_Form_1130A-2_FINAL_01.08.10.docx	Supplementary Document	Uploaded 2010-01-22	Available
Narrative_of_Revisions.doc	Supplementary Document	Uploaded 2010-03-10	Available
privacy_pia_tsa_hraccess[1].pdf	Supplementary Document	Uploaded 2010-01-15	Available
HRAccess PTA 4-30-2009.pdf	Supplementary Document	Uploaded 2010-01-15	Available
30-Day FR Renewal Notice.pdf	Supplementary Document	Uploaded 2010-01-15	Available
60-Day_FR_Renewal_Notice.pdf	Supplementary Document	Uploaded 2010-01-04	Available
44 USC 44935.doc	Supplementary Document	Uploaded 2006-09-15	Available
TSO-Med_Renew_1652-0032_SS_FINAL.doc	Supporting Statement A	Uploaded 2010-03-10	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
44985	Vital Signs FE form	Form and Instruction	Removed	Vital Signs further evaluation
44984	Vision FE form	Form and Instruction	Removed	Vision further evaluation
44983	TB FE form	Form and Instruction	Removed	TB further evaluation
44982	Seizure FE form	Form and Instruction	Removed	Seizure further evaluation
44981	Respiratory FE form	Form and Instruction	Removed	Respiratory further evaluation
44980	Palmar Sensation FE form	Form and Instruction	Removed	Palmar Sensation further evaluation
44979	Orthopedic FE form	Form and Instruction	Removed	Orthopedic further evaluation
44978	Mental Health FE form	Form and Instruction	Removed	Mental Health further evaluation
44977	Implanted Medical Device FE form	Form and Instruction	Removed	Implanted Medical Device further evaluation
44976	HIV FE form	Form and Instruction	Removed	HIV further evaluation
44975	Hernia FE form	Form and Instruction	Removed	Hernia further evaluation
44974	Hepatitus FE form	Form and Instruction	Removed	Hepatitus Further Evaluation
44973	Hearing FE form	Form and Instruction	Removed	Hearing Further Evaluation
44972	General FE form	Form and Instruction	Removed	General Further Evaluation
44971	Drug Alcohol Use FE form	Form and Instruction	Removed	Drug Alcohol Use Further Evaluation
44970	Diabetes FE form	Form and Instruction	Removed	Diabetes Further Evaluation
44969	Cardiac Surgery FE form	Form and Instruction	Removed	Cardiac Surgery further evaluation
44968	Cardiac FE form	Form and Instruction	Removed	Cardiac Further Evaluation form
44935	Cancer FE form	Form and Instruction	Removed	Further Evaluation Form Cancer
20961	Transportation Security Officer Medical Questionnaire	Form and Instruction	Removed	Transportation Security Officer Medical Questionnaire
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Vital Signs Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Vision Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	TB Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Seizure Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Respiratory Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Palmar Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Orhopedic
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Mental Health Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Pacemaker Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	HIV Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Hernia Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Hepatitis Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Hearing Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	General Medical Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Drug Use Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Diabetes Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Cardiac Surgery Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Cardiac Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	Cancer Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	New	TSO Medical Questionnaire

ICR Details

OMB Control No: 1652-0032	ICR Reference No: 201001-1652-001
Status: Historical Active	Previous ICR Reference No: 200608-1652-003
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: 03/16/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/22/2010
Terms of Clearance: Approved for 2 years with this ToC: This collection is approved for only two years due to lack of full GPEA compliance.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved	03/31/2010
Responses	26,565	0	68,438
Time Burden (Hours)	12,912	0	22,813
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
  

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:
	74 FR 55060	10/26/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 2556	01/15/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Cancer FE form	n/a	Further Evaluation Form Cancer
Cardiac FE form	n/a	Cardiac Further Evaluation form
Cardiac Surgery FE form	n/a	Cardiac Surgery further evaluation
Diabetes FE form	n/a	Diabetes Further Evaluation
Drug Alcohol Use FE form	n/a	Drug Alcohol Use Further Evaluation
General FE form	n/a	General Further Evaluation
HIV FE form	n/a	HIV further evaluation
Hearing FE form	n/a	Hearing Further Evaluation
Hepatitus FE form	n/a	Hepatitus Further Evaluation
Hernia FE form	n/a	Hernia further evaluation
Implanted Medical Device FE form	n/a	Implanted Medical Device further evaluation
Mental Health FE form	n/a	Mental Health further evaluation
Orthopedic FE form	n/a	Orthopedic further evaluation
Palmar Sensation FE form	n/a	Palmar Sensation further evaluation
Respiratory FE form	n/a	Respiratory further evaluation
Seizure FE form	n/a	Seizure further evaluation
TB FE form	n/a	TB further evaluation
TSO Medical Questionnaire and Evaluation	TSA Form 1130B-3, TSA Form 1130B-4, TSA Form 1130B-18, TSA Form 1130B-5, TSA Form 1130B-6, TSA Form 1130B-7, TSA Form 1130A-1, TSA Form 1130B-1, TSA Form 1130B-14, TSA Form 1130B-2, TSA Form 1130B-8, TSA Form 1130B-9, TSA Form 1130B-10, TSA Form 1130B-15, TSA Form 1130B-19, TSA Form 1130B-11, TSA Form 1130B-12, TSA Form 1130B-13, TSA Form 1130B-16, TSA Form 1130B-17	TSO Medical Questionnaire ,   Cancer Further Evaluation ,   Cardiac Further Evaluation ,   Cardiac Surgery Further Evaluation ,   Diabetes Further Evaluation ,   Drug Use Further Evaluation ,   General Medical Further Evaluation ,   Hearing Further Evaluation ,   Hepatitis Further Evaluation ,   Hernia Further Evaluation ,   HIV Further Evaluation ,   Pacemaker Further Evaluation ,   Mental Health Further Evaluation ,   Orhopedic ,   Palmar Further Evaluation ,   Respiratory Further Evaluation ,   Seizure Further Evaluation ,   TB Further Evaluation ,   Vision Further Evaluation ,   Vital Signs Further Evaluation
Transportation Security Officer Medical Questionnaire	N/A	Transportation Security Officer Medical Questionnaire
Vision FE form	n/a	Vision further evaluation
Vital Signs FE form	n/a	Vital Signs further evaluation

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ICR Summary of Burden

table that charts list 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	26,565	68,438	0	-41,873	0	0
Annual Time Burden (Hours)	12,912	22,813	0	-9,901	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The burden has decreased based on the number of respondents. The number of TSO hiring has decreased.

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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)? No

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: 01/22/2010

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