Office of Law Enforcement/Federal Air Marshal Service (OLE/FAMS) Mental Health Certification

Forms and Documents

Document Name	Status
Form TSA FORM 1164 FAMS Mental Health Certification Form and Instruction	Modified
FAMS_Mental_Cert_SS_101810.docx Supporting Statement A	2010-10-18
DHS-TSA 001.pdf Supplementary Document	2010-09-24
OPM-GOVT-10%20-%20Medical%20Records[1].pdf Supplementary Document	2010-09-24
Narrative_of_Changes_1652-0043.doc Supplementary Document	2010-09-23
30 Day Notice.pdf Supplementary Document	2010-09-23
60 Day Notice.pdf Supplementary Document	2010-09-13
49 USC 44917[1].doc Supplementary Document	2007-08-29
49 USC 44903[1].doc Supplementary Document	2007-08-29
49 USC 44901[1].doc Supplementary Document	2007-08-29

IC Document Collections

IC ID	Document Title	Status
46519	FAMS Mental Health Certification Form and Instruction	Modified

ICR Details

OMB Control No: 1652-0043	ICR Reference No: 201009-1652-001
Status: Historical Active	Previous ICR Reference No: 200708-1652-004
Agency/Subagency: DHS/TSA	Agency Tracking No:
Title: Office of Law Enforcement/Federal Air Marshal Service (OLE/FAMS) Mental Health Certification
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/17/2011
	Date Received in OIRA: 10/19/2010
Terms of Clearance: In future submissions, TSA should clarify some of the types of conditions that may require follow-up, and, the types of information required to facilitate MHC clearance.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2012	36 Months From Approved	06/30/2011
Responses	10,000	0	10,000
Time Burden (Hours)	10,000	0	10,000
Cost Burden (Dollars)	4,400	0	4,100

---

Abstract: In furtherance of TSA's authority to provide for deployment of Federal Air Marshals (FAMs) on passenger flights, and provide for appropriate training, supervision, and equipment of FAMs TSA policy requires that applicants for Office of Law Enforcement/ Federal Air Marshal positions meet certain medical standards, which includes a psychological evaluation. Applicants will be required to complete a certification regarding their mental health history and provide an explanation for anything they cannot certify. This certification is carefully geared to capitalize on other elements of the assessment process, such as personal interviews, physical task assessment, background investigation, as well as the other components of the medical examination and assessment.

---

Authorizing Statute(s): US Code: 49 USC 44901 Name of Law: ATSA
   US Code: 49 USC 44903 Name of Law: ATSA
   US Code: 49 USC 44917 Name of Law: ATSA
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 34148	06/16/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 57049	09/17/2010
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
FAMS Mental Health Certification	TSA FORM 1164	Mental Health Certification

---

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	10,000	10,000	0	0	0	0
Annual Time Burden (Hours)	10,000	10,000	0	0	0	0
Annual Cost Burden (Dollars)	4,400	4,100	0	0	300	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $67,250

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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 10/19/2010

---