Notification of Medical Hold Further Evaluation

Notification of Medical

Hold Further Evaluation

Candidate’s Name: {LastName}, {FirstName}	Last 4 Digits of SSN: {xxxSSN}
Location of Assessment: {Clinic}	Date: {ExamDate}

You have been placed on medical hold/further evaluation. Comprehensive Health Services, (CHS) requires additional medical information from you or your physician in order for your medical assessment to be completed. Any expenses incurred remain your responsibility and will not be reimbursed by CHS or TSA.

You have been placed on medical hold/further evaluation for the following reason(s):

Vision

Hearing

Vital Signs (Pulse and / or Blood Pressure)

Positive Glucose and/or Ketone results

Decrease or absent palmar sensation

History of Cardiac condition or cardiac surgery

History of Eye surgery

History of a Respiratory condition

History of a positive TB test

History of a Gastrointestinal condition

History of a Hepatic (liver) condition

History of a Musculoskeletal / Orthopedic condition or surgery

History of Diabetes, Thyroid disease or Blood disorder

History of a Neurological condition

History of a Mental Health, Psychological or substance dependency condition

Other: _________________________________________________________________

Other: _________________________________________________________________

Other: _________________________________________________________________

How to complete the Medical Hold / Further Evaluation process

1. Take the attached “Further Evaluation” form(s) to your physician

2. Have your physician read, complete and sign the form(s) and provide ALL requested supporting documentation

3. If you are evaluated by a physician assistant or nurse practitioner, a physician must co-sign the form

4. Make sure that the physician also provides you and CHS with the additional information requested on the forms such as progress notes or test results

5. CHS cannot complete your medical assessment without all forms being fully completed and signed

6. Make sure that the information is legible and complete

7. If CHS does not receive your completed forms and requested supporting documentation within 90 DAYS of the date above, you will not receive further consideration in the application process to become a Transportation Security Officer (Screener). Extensions of this deadline will not be considered.

8. FAX all completed further evaluation forms with progress notes and test results to 703-288-5495.

9. If you have any additional questions please contact:

Comprehensive Health Services

8810 Astronaut Blvd.

Cape Canaveral, FL 32920

Phone: 866-416-5928

Fax: 703-288-5495

TSA Form 1130A-2, 12/09 [File: 1100.0.1]