Transportation Security Officer Medical Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TSA Form 1130B-19 Vital Signs Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-18 Vision Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-17 TB Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-16 Seizure Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-15 Respiratory Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-14 Palmar Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-13 Orhopedic	Form and Instruction	Modified	Available
Form TSA Form 1130B-12 Mental Health Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-11 Pacemaker Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-10 HIV Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-9 Hernia Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-8 Hepatitis Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-7 Hearing Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-6 General Medical Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-5 Drug Use Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-4 Diabetes Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-3 Cardiac Surgery Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-2 Cardiac Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130B-1 Cancer Further Evaluation	Form and Instruction	Modified	Available
Form TSA Form 1130A-1 TSO Medical Questionnaire	Form and Instruction	Modified	Available
RELEASE - TSA_Form_1130A-3_FINAL_01.08.10.docx	Supplementary Document	Uploaded 2010-01-22	Repair queued
NOTIFICATION - TSA_Form_1130A-2_FINAL_01.08.10.docx	Supplementary Document	Uploaded 2010-01-22	Available
privacy_pia_tsa_hraccess[1].pdf	Supplementary Document	Uploaded 2010-01-15	Available
HRAccess PTA 4-30-2009.pdf	Supplementary Document	Uploaded 2010-01-15	Available
TSO_Med_30DayFR.pdf	Supplementary Document	Uploaded 2012-03-14	Available
TSO_Med_60DayFR.pdf	Supplementary Document	Uploaded 2012-03-14	Available
44 USC 44935.doc	Supplementary Document	Uploaded 2006-09-15	Available
TSO-Med_SS.docx	Supporting Statement A	Uploaded 2012-03-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Vital Signs Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Vision Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	TB Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Seizure Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Respiratory Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Palmar Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Orhopedic
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Mental Health Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Pacemaker Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	HIV Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Hernia Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Hepatitis Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Hearing Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	General Medical Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Drug Use Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Diabetes Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Cardiac Surgery Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Cardiac Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	Cancer Further Evaluation
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	TSO Medical Questionnaire

ICR Details

OMB Control No: 1652-0032	ICR Reference No: 201203-1652-001
Status: Historical Inactive	Previous ICR Reference No: 201001-1652-001
Agency/Subagency: DHS/TSA	Agency Tracking No:
Title: Transportation Security Officer Medical Questionnaire
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 08/08/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/30/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved	08/31/2012
Responses	26,565	0	26,565
Time Burden (Hours)	12,912	0	12,912
Cost Burden (Dollars)	0	0	0

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Abstract: This collection of information will assist the agency in ensuring that candidates under employment consideration for Transportation Security Officer (TSO) positions meet the qualification standards to successfully perform the functions of the position. The information will be collected from applicants for TSO positions to evaluate a candidate's candidate’s current and past medical history including visual and aural acuity, physical coordination, and motor skills.

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Authorizing Statute(s): US Code: 49 USC 44935
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 82313	12/30/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 15114	03/14/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
TSO Medical Questionnaire and Evaluation	TSA Form 1130B-3, TSA Form 1130B-4, TSA Form 1130B-18, TSA Form 1130B-5, TSA Form 1130B-6, TSA Form 1130B-7, TSA Form 1130A-1, TSA Form 1130B-1, TSA Form 1130B-14, TSA Form 1130B-2, TSA Form 1130B-8, TSA Form 1130B-9, TSA Form 1130B-10, TSA Form 1130B-15, TSA Form 1130B-19, TSA Form 1130B-11, TSA Form 1130B-12, TSA Form 1130B-13, TSA Form 1130B-16, TSA Form 1130B-17	TSO Medical Questionnaire ,   Cancer Further Evaluation ,   Cardiac Further Evaluation ,   Cardiac Surgery Further Evaluation ,   Diabetes Further Evaluation ,   Drug Use Further Evaluation ,   General Medical Further Evaluation ,   Hearing Further Evaluation ,   Hepatitis Further Evaluation ,   Hernia Further Evaluation ,   HIV Further Evaluation ,   Pacemaker Further Evaluation ,   Mental Health Further Evaluation ,   Orhopedic ,   Palmar Further Evaluation ,   Respiratory Further Evaluation ,   Seizure Further Evaluation ,   TB Further Evaluation ,   Vision Further Evaluation ,   Vital Signs Further Evaluation

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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:

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Annual Cost to Federal Government: $2,556,241

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

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Common Form ICR:  No

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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: 03/30/2012

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