Transportation Security Officer Medical Questionnaire

Forms and Documents

Document Name	Status
Form TSA Form 1130B-12 TSO Medical Questionnaire and Evaluation Form and Instruction	Modified
TSO_Med_30DayFR.pdf Supplementary Document	2013-01-27
TSO_Med_60DayFR.pdf Supplementary Document	2013-01-27
TSO-Med_SS.docx Supporting Statement A	2013-01-27
RELEASE - TSA_Form_1130A-3_FINAL_01.08.10.docx Supplementary Document	2010-01-22
NOTIFICATION - TSA_Form_1130A-2_FINAL_01.08.10.docx Supplementary Document	2010-01-22
privacy_pia_tsa_hraccess[1].pdf Supplementary Document	2010-01-15
HRAccess PTA 4-30-2009.pdf Supplementary Document	2010-01-15
44 USC 44935.doc Supplementary Document	2006-09-15

IC Document Collections

IC ID	Document Title	Status
191700	TSO Medical Questionnaire and Evaluation Form and Instruction	Modified

ICR Details

OMB Control No: 1652-0032	ICR Reference No: 201301-1652-006
Status: Historical Active	Previous ICR Reference No: 201001-1652-001
Agency/Subagency: DHS/TSA	Agency Tracking No:
Title: Transportation Security Officer Medical Questionnaire
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/29/2013
	Date Received in OIRA: 01/29/2013
Terms of Clearance: Upon resubmission, TSA should include a plan for electronic submission of information. In addition, TSA should provide an estimate of the additional costs to respondents for follow-up and compliance.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved
Responses	26,565	0	0
Time Burden (Hours)	12,912	0	0
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 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 Name of Law: null
  

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

IC Title	Form No.	Form Name
TSO Medical Questionnaire and Evaluation	TSA Form 1130A-1, TSA Form 1130B-2, TSA Form 1130B-1, TSA Form 1130B-3, TSA Form 1130B-4, TSA Form 1130B-5, TSA Form 1130B-6, TSA Form 1130B-7, TSA Form 1130B-8, TSA Form 1130B-9, TSA Form 1130B-10, TSA Form 1130B-11, TSA Form 1130B-12, TSA Form 1130B-13, TSA Form 1130B-14, TSA Form 1130B-15, TSA Form 1130B-16, TSA Form 1130B-17, TSA Form 1130B-18, TSA Form 1130B-19	Mental Health Further Evaluation ,   Orthopedic Further Evaluation ,   Palmar Further Evaluation ,   Respiratory Further Evaluation ,   Seizure Further Evaluation ,   Tuberculosis Further Evaluation ,   Vision Further Evaluation ,   Vital Signs Further Evaluation ,   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

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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	26,565	0	0	0	0	26,565
Annual Time Burden (Hours)	12,912	0	0	0	0	12,912
Annual Cost Burden (Dollars)	0	0	0	0	0	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:

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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: 01/29/2013

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