Information Collection

FAMS Mental Health Certification

IC 46519 under ICR 201009-1652-001 · OMB 1652-0043.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0043 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TSA FORM 1164 Mental Health Certification FAMS Mental Health Certification	Form and Instruction
TSA FORM 1164 Mental Health Certification MHC FINAL.doc	Form and Instruction

IC Title:

FAMS Mental Health Certification

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 14 CFR 67

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	TSA FORM 1164				No		Fillable Fileable Signable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title: Employee Medical File System Records

FR Citation: 65 FR 24750

Number of Respondents: 10,000

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	10,000	0	10,000
Annual IC Time Burden (Hours)	10,000	0	10,000
Annual IC Cost Burden (Dollars)	4,400	300	4,100

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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