Information Collection

TSO Medical Questionnaire and Evaluation

IC 191700 under ICR 201001-1652-001 · OMB 1652-0032.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0032 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TSA Form 1130A-1 TSO Medical Questionnaire and Evaluation	Form and Instruction
TSA Form 1130A-1 TSO Medical Questionnaire TSA_Form_1130A-1_FINAL_01 14 10 (3).pdf	Form and Instruction
TSA Form 1130B-1 Cancer Further Evaluation CANCER - TSA_Form_1130B-1_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-2 Cardiac Further Evaluation CARDIAC - TSA_Form_1130B-2_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-3 Cardiac Surgery Further Evaluation CARDIAC SURGERY- TSA_Form_1130B-3_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-4 Diabetes Further Evaluation DIABETES - TSA_ Form_1130B-4_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-5 Drug Use Further Evaluation DRUG USE - TSA_Form_1130B-5_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-6 General Medical Further Evaluation GENERAL MED - TSA_Form_1130B-6_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-7 Hearing Further Evaluation HEARING - TSA_Form_1130B-7_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-8 Hepatitis Further Evaluation HEPATITIS - TSA_Form_1130B-8_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-9 Hernia Further Evaluation HERNIA - TSA_Form_1130B-9_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-10 HIV Further Evaluation HIV - TSA_Form_1130B-10_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-11 Pacemaker Further Evaluation PACEMAKER - TSA_Form_1130B-11_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-12 Mental Health Further Evaluation MENTAL HEALTH - TSA_Form_1130B-12_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-13 Orhopedic ORTHOPEDIC - TSA_Form_1130B-13_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-14 Palmar Further Evaluation PALMAR - TSA_Form_1130B-14_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-15 Respiratory Further Evaluation RESPIRATORY - TSA_Form_1130B-15_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-16 Seizure Further Evaluation SEIZURE - TSA_Form_1130B-16_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-17 TB Further Evaluation TB - TSA_Form_1130B-17_ FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-18 Vision Further Evaluation VISION - TSA_Form_1130B-18_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-19 Vital Signs Further Evaluation VITAL SIGNS - TSA_Form_1130B-19_FINAL_ 01.08.10.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

TSO Medical Questionnaire and Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	TSA Form 1130A-1	TSO Medical Questionnaire	TSA_Form_1130A-1_FINAL_01 14 10 (3).pdf	No	Paper Only
Form and Instruction	TSA Form 1130B-1	Cancer Further Evaluation	CANCER - TSA_Form_1130B-1_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-2	Cardiac Further Evaluation	CARDIAC - TSA_Form_1130B-2_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-3	Cardiac Surgery Further Evaluation	CARDIAC SURGERY- TSA_Form_1130B-3_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-4	Diabetes Further Evaluation	DIABETES - TSA_ Form_1130B-4_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-5	Drug Use Further Evaluation	DRUG USE - TSA_Form_1130B-5_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-6	General Medical Further Evaluation	GENERAL MED - TSA_Form_1130B-6_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-7	Hearing Further Evaluation	HEARING - TSA_Form_1130B-7_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-8	Hepatitis Further Evaluation	HEPATITIS - TSA_Form_1130B-8_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-9	Hernia Further Evaluation	HERNIA - TSA_Form_1130B-9_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-10	HIV Further Evaluation	HIV - TSA_Form_1130B-10_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-11	Pacemaker Further Evaluation	PACEMAKER - TSA_Form_1130B-11_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-12	Mental Health Further Evaluation	MENTAL HEALTH - TSA_Form_1130B-12_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-13	Orhopedic	ORTHOPEDIC - TSA_Form_1130B-13_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-14	Palmar Further Evaluation	PALMAR - TSA_Form_1130B-14_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-15	Respiratory Further Evaluation	RESPIRATORY - TSA_Form_1130B-15_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-16	Seizure Further Evaluation	SEIZURE - TSA_Form_1130B-16_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-17	TB Further Evaluation	TB - TSA_Form_1130B-17_ FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-18	Vision Further Evaluation	VISION - TSA_Form_1130B-18_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-19	Vital Signs Further Evaluation	VITAL SIGNS - TSA_Form_1130B-19_FINAL_ 01.08.10.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 26,565

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	26,565	26,565
Annual IC Time Burden (Hours)	12,912	12,912
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.