TSA-1915 CMST Certification Roster

C MSDT Certification Roster

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INSTRUCTIONS: Trainees and Trainers provide requested information below to document attendance and completion of Crew Member Self-defense Training (CMSDT) and certification status.

LOCATION:	     							DATE:	     
TRAINEE INFORMATION											COMPLETED BY TRAINER
Name			Airline Affiliation	Airline ID #	2nd ID #	Contact Information Mailing Address, Email, and Phone #					Participant	Observer		Certified
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Signature:      			     	     	     	     								Yes No
						     
Trainer Name: (print)		     				Signature:					Date:

PRIVACY ACT STATEMENT: Authority: 49 U.S..C §§ 114, 44918. Principle Purpose(s): TSA is collecting information from airline crew members who have volunteered to participate in TSA-sponsored crew member self-defense training. Routine Use(s): TSA will use the information you provide to confirm your eligibility for this training, to keep track of which individuals have completed the training, and for program management and evaluation purposes. You are not required to participate in this training or provide the requested information; however, if you do not provide the requested information you may not be permitted to participate in the training. Disclosure: This information may be disclosed to TSA contractors who are assisting TSA with the training, to training facilities for purposes of enrollment and verification of employee attendance and performance, or for routine uses identified in the Privacy Act system of records notice DHS/ALL 003, Department of Homeland Security General Training Records (May 8, 2006, 71 FR 26767).

PAPERWORK REDUCTION ACT STATEMENT: Through this information collection, TSA is gathering information about you to confirm your attendance at TSA’s crew member self-defense training course. The public burden for this collection of information is estimated to be five minutes. This is a voluntary collection of information. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0028, which expires 10/31/2011.

Previous editions of this form are obsolete. Page ____ of ____

TSA Form 1915, 2/09 rev. [File: 1900.1.1-a] OMB Control No. 1652-0028, which expires 10/31/2011