TSA Form 1130A-1 TSO Medical Questionnaire

Transportation Security Officer
Medical Questionnaire
PAPERWORK REDUCTION ACT & PRIVACY ACT STATEMENT
The Transportation Security Administration (TSA) requires physical/medical examinations prior to an individual’s appointment to a TSA Security Officer position. TSA uses this
form to obtain information relevant to an applicant’s health status for purposes of making an employment decision. This is a mandatory collection of information if you wish to be
considered for a TSA Security Officer position. It is estimated that the total average burden per response associated with this form is approximately 40 minutes. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number.
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 44935 PRINCIPAL PURPOSE(S): This information will be used to determine your eligibility for employment as a
Transportation Security Officer (TSO). ROUTINE USE(S): This information may be shared with contractors, grantees, or volunteers performing or working on a contract, service,
grant, cooperative agreement, or job for the federal government, or for routine uses identified in the Office of Personnel Management’s system of records notice, OPM/GOVT-10
Employee Medical File System Records (if hired) or OPM/GOVT-5 Recruiting, Examining, and Placement Records (if not hired). DISCLOSURE: Voluntary; failure to furnish the
requested information may result in an inability to consider your application for employment.

INSTRUCTIONS
It is required that you complete each question or response in this questionnaire. After completing each page record your initials in the space provided at the bottom of each page.
Your responses will be reviewed with you by a medical professional.

DEMOGRAPHIC INFORMATION
Name (Print):

______________________________________

Address:

______________________________________

Social Security # (last 4 digits):

______________________________________

Sex: Male _______ Female _______

Home Phone #:

(__ __ __) __ __ __ - __ __ __ __

Date of Birth: _____/_____/________

Work Phone #:

(__ __ __) __ __ __ - __ __ __ __

Other Phone #:

(__ __ __) __ __ __ - __ __ __ __

___ ___ ___ ___

(mm / dd / yyyy)

Height:

______Feet ______Inches

Weight:

______lbs

Best Time to Call: ______________________________________

GENERAL INFORMATION
1. Have you been refused employment,dismissed from a job,or unable to
stay in school due to any medical condition or excessive absenteeism?

1. Yes_____

No______

2. Yes_____

No______

3. Yes_____

No______

4. Have you been treated at any type of hospital in the last 10 years?
If yes , specify when and reason for treatment

4. Yes_____

No______

5. Have you ever had any illness, injury, or condition (including learning
disability, attention deficit disorder, etc.) other than those already noted
above?

5. Yes_____

No______

If yes, please list each medical condition and record the year of the refusal:

2. Have you ever been diagnosed or treated for a mental health condition?
If yes , specify the year for each mental health condition and provide details:

3. Have you had, or have you been advised to have, any operations?
If yes , describe what type of operation and indicate date if appropriate

Don't Know ______

If yes , specify medical condition and when you were treated

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Page 1 of 6

Candidate Initials _________

GENERAL INFORMATION (continued)
6. Have you consulted or been treated by clinics, physicians, healers, or
6. Yes_____
other practitioners within the past year for anything other than minor
illnesses?
If yes , provide an explanation and the name of doctor consulted and/or the hospital/clinic

No______

7. Have you ever been rejected for military service or law enforcement
position(s) because of physical, mental, or other medical reasons?
If yes , give date and reason for rejection:

No______

7. Yes_____

8. Have you ever been discharged from military service or a law
8. Yes_____
No______
enforcement position because of physical, mental, or other reasons?
If yes , give date and reason. If military discharge, list type (e.g., honorable, other than honorable, for unfitness, unsuitability):

9. Have you ever received a pension or compensation for a disability or
work related injury or illness?
If yes , complete the chart below for each occurrence:

Disability

1
2
3

Year
Disability
Granted

Disability related to which body system?
Check one.

% Disability
Granted

9. Yes_____

No______

Duration of Disability
(Years/Months)

Is disability
permanent?
(Yes/No)

Musculoskeletal
Mental Health
Other
Musculoskeletal
Mental Health
Other
Musculoskeletal
Mental Health
Other

10 Yes_____
10.
Y

Do you h
10 D
10.
have a valid
lid d
driver's
i ' lilicense?
?

N
No______

11. Yes_____
11. Are you taking any prescription medications?
No______
If yes , list all current prescription medications and check the box that best describes how often you take each medication
Name of Medication

Daily

Weekly

Monthly or Less

VISION:
1. Do you have a total loss of vision in your right eye?
2. Do you have a total loss of vision in your left eye?
3. Have you had any type of eye surgery (such as Lasik,
cataracts, etc.) in the past year?

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Page 2 of 6

1. Yes_____

No______

2. Yes_____

No______

3. Yes_____

No______

Candidate Initials _________

MEDICAL HISTORY
HEARING:
1. Do you have a total loss of hearing in your right ear?
2. Do you have a total loss of hearing in your left ear?
3. Do you wear hearing aids?
If yes, is it a CROS style hearing aid?

CARDIOVASCULAR:

2. Bronchitis
3. Blood in sputum or when coughing
4. Past history or diagnosis of lung disease
5. History of tuberculosis
6. Positive TB test
7. Asthma

No______

Don't Know ______

3. Yes_____

No______

Yes_____

No______

1. Yes_____
Yes_____
2. Yes_____
Yes_____
3. Yes_____
Yes_____
4. Yes_____
5. Yes_____
6. Yes_____
7. Yes_____
8. Yes_____
9. Yes_____
a. Yes_____
b. Yes_____
10. Yes_____

No______
No______
No______
No______
No______
No______
No______
No______
No______
No______
No______
No______
No______
No______
No______

11. Yes_____
12. Yes_____
13. Yes_____

No______
No______
No______

Don't Know ______

Don't Know
Don't Know
Don't Know
Don't Know
Don't Know

______
______
______
______
______

Don't Know ______
Don't Know ______
Don't Know ______

1. Yes_____
No______
If yes , how long ago? ____________
2. Yes_____
Yes
No
No______
Don'tt Know ______
Don
If yes , how long ago? ____________
No______ Don't Know ______
3. Yes_____
If yes , how long ago? ____________
4. Yes_____
No______
If yes , how long ago? ____________
5. Yes_____
No______
If yes , how long ago? ____________
6. Yes_____
No______
If yes , how long ago? ____________
7. Yes_____
No______ Don't Know ______
If yes , how long ago? ____________

Have you EVER had or experienced any of the following?
1. Yes_____
No______
If yes , how long ago? ____________
2. Yes_____
No______
If yes , how long ago? ____________
3. Yes_____
No______ Don't Know ______
If yes , how long ago? ____________

1. Persistent stomach or abdominal pain
2. Persistent diarrhea or constipation
3. Blood in stool

HEPATIC:

2. Yes_____

Have you EVER had or experienced any of the following?

1. Problems breathing, wheezing, persistent cough or shortness of breath

GASTROINTESTINAL:

Don't Know ______

Have you EVER had or experienced any of the following?

1. Chest pains
If yes, has your doctor prescribed heart medication for this?
2. Palpitations (rapid or skipped heart beat)
If yes, are you receiving treatment?
3. Heart murmur
If yes, has anyone ever recommended heart valve replacement?
4. Heart valve replacement
5. Past history or diagnosis of heart disease
6. Coronary bypass surgery or other heart surgery
7. Heart attack or stroke
8. Abnormal EKG or stress test result
9. Pacemaker or implanted defibrillator
a. Pacemaker?
b. Implanted defibrillator?
10. High blood pressure
11. Circulatory problems (e.g., Raynaud's disease, swelling of ankles, leg
pains, numbness in feet or hands)
12. Cramps in legs
13. Phlebitis or blood clots

RESPIRATORY:

No______

1. Yes_____

Have you EVER had or experienced any of the following?
1. Yes_____
No______ Don't Know ______
If yes , how long ago? ____________
2. Yes_____
No______ Don't Know ______
If yes , how long ago? ____________

1. Liver disease, jaundice or history of cirrhosis
2. Hepatitis

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Page 3 of 6

Candidate Initials _________

MEDICAL HISTORY (continued)
MUSCULOSKELETAL / ORTHOPEDIC:

Have you EVER had or experienced any of the following?

1. Amputated hand or missing hand
2. Any other amputation (e.g., leg, finger, toe)
3. Back pain
a. How often do you experience it?
b. How often do you take medication for your pain?
4. Back surgery
5. Back injury
6. Joint pain or swelling
7. Loss of joint or limb movement
8. Loss of strength or muscle weakness
9. Difficulty walking
10. Difficultly bending, stooping or squatting
11. Difficulty reaching overhead, moving arms in all directions at shoulders
12. Arthritis, rheumatism, bursitis or gout
13. Bone, joint, or other deformity
14. Foot problems (aching, pain when walking in bare feet)
15. Any orthopedic surgery within the past two years
16. Any neck (cervical spine) surgery
17. Any neck (cervical spine) problems or disorder
18. Any fracture(s) with symptoms and/or abnormal range of motion
19. Plate, pin, or rod in any bone

1.
2.
3.
a.
b.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.

Yes_____
No______
No______
Yes_____
Yes_____
No______
Frequently ____ Occasionally ____
Frequently ____ Occasionally ____ Never ____
Yes_____
No______
Yes_____
No______
Yes_____
No______
Yes_____
No______
Yes_____
No______
Yes_____
No______
Yes_____
No______
No______
Yes_____
Yes_____
No______ Don't Know ______
Yes_____
No______
Yes_____
No______
No______
Yes_____
Yes_____
No______
No______
Yes_____
Yes_____
No______ Don't Know ______
Yes_____
No______

20. Check the statement below that best describes how long you can sit continuously without standing or walking:
I am physically able to sit continuously without taking a break for a total of:
Less than 1 hour in an 8-hour workday
At least 1 to 2 hours in an 8-hour workday
At least 3 to 4 hours in an 8-hour workday
At least 5 to 6 hours in an 8-hour workday
21. Check the statement below that best describes how long you can stand and walk continuously without sitting or leaning
against a table or wall:
I am physically able to stand and walk continuously without taking a break for a total of:
Less than 1 hour in an 8-hour workday
At least 1 to 2 hours in an 8-hour workday
At least 3 to 4 hours in an 8-hour workday
At least 5 to 6 hours in an 8-hour workday
22. Do you have any lifting restrictions?
If yes, what is the maximum weight you are allowed to lift?

22. Yes_____

No______
pounds

23. Place a check next to the response that best describe how often you lift and/or carry objects for each weight category:
Lift and/or carry (including upward pulling) a maximum of:
Occasionally
Never / Rarely
Weight
0 to 2 times per year

30 pounds
50 pounds
70 pounds

1 to 2 times per month

Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________

Frequently
Once per week or more

Frequently
Frequently
Frequently

24. How often do you participate in each of the following activities?
Weight
Climb (Stairs)
Stoop/Bend/Squat
Kneel

Never / Rarely

Occasionally

Frequently

0 to 2 times per year

1 to 2 times per month

Once per week or more

Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________

25. If you have a limitation performing any of the tasks listed below,
place a check in the box (right, left) that corresponds to the side of
your body with the limitation. Otherwise, check "No Limitations".
a.
b.
c.
d.

Frequently
Frequently
Frequently

Limitations
Right
Left

No
Limitations

Can handle or pick up objects from a table with fingers
Can feel objects with fingers and hands (sensation)
Can touch finger tips to palm to make a fist
Can bend elbow and touch fingers to shoulder

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Page 4 of 6

Candidate Initials _________

MEDICAL HISTORY (continued)
ENDOCRINE:
1.
2.
3.
4.

Have you EVER had or experienced any of the following?
Diabetes
Thyroid disease
Anemia
Blood disorder

1.
2.
3.
4.

Yes______
Yes______
Yes______
Yes______

No______
No______
No______
No______

Don't Know
Don't Know
Don't Know
Don't Know

______
______
______
______

NEUROLOGICAL:
Have you EVER had or experienced any of the following?
1. Yes______
No______
1. Localized weakness, numbness, tingling, or loss of sensation in hands,
legs, or feet
If yes , how long ago? ____________
2. Yes______
No______ Don't Know
If yes , how long ago? ____________
3. Yes______
No______ Don't Know
If yes , how long ago? ____________
4. Yes______
No______
If yes , how long ago? ____________
5. Yes______
No______ Don't Know
If yes , how long ago? ____________
6. Yes______
No______
If yes , how long ago? ____________
7. Yes______
No______
If yes , how long ago? ____________
8. Yes______
No______ Don't Know
If yes , how long ago? ____________
9. Yes______
No______
If yes , how long ago? ____________

2. Seizures
3. Tremors or shakiness
4. Fainting or dizziness
5. Head injury
6. Wear a brace or back support
7. Frequent or severe headaches
8. Nerve injury
9. Paralysis

PSYCHOLOGICAL:
Have you EVER had or experienced any of the following?
1. Yes______
1. Counseling or psychiatric consultation
No______
If yes , how long ago? ____________
2. Yes______
2. Episodes of depression
No______ Don't Know
If yes , how long ago? ____________
3. Yes______
3. Periods of nervousness or anxiety
No______ Don't Know
If yes , how long ago? ____________
4. Yes______
4. Prescribed medication for a mental health condition
No______ Don't Know
If yes , how long ago? ____________
5. Yes______
No______ Don't Know
5. History of alcoholism or alcohol use
If yes , how
h
llong ago?
? ____________
6. Yes______
No______ Don't Know
6. History of substance or drug use
If yes , how long ago? ____________
7. Yes______
7. Suicide attempt or plans
No______
If yes , how long ago? ____________

______
______

______

______

______
______
______
______
______

GENERAL HISTORY
Answer the following questions:
1. Have you had an organ transplant?
2. Are you currently using, or have you in the past used, any narcotic
medication or other prescription painkiller?
3. Are you currently using, or have you in the past used, sedating
medication or tranquilizers?
4. Do you currently have or in the past had a hernia?
a. Has it been surgically repaired?
b. Date of repair? ___________
5. Do you have any skin problems/disease (e.g., urticaria, eczema,
dermatitis, psoriasis)?
6. Do you currently have or in the past had cancer?
a. Type of cancer? _________________________________________

1. Yes______

No______

2. Yes______

No______

3. Yes______
4. Yes______
a. Yes______

No______
No______
No______

Don't Know ______
Don't Know ______

5. Yes______
6. Yes______

No______
No______

Don't Know ______

7. Yes______
8. Yes______

No______
No______

Don't Know ______

b. Date of diagnosis? _______________________________________
c. Date of last treatment? ____________________________________
7. Do you have narcolepsy or a sleep disorder?
8. Do you use tobacco?

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Page 5 of 6

Candidate Initials _________

GENERAL HISTORY (continued)
9. Check the statement below that best describes your ability to lift and carry:
I affirm that I am physically able to pick up and carry a distance of
25 feet (for example, the distance to cross a two-lane street):
30 lbs. (for example, 2 cases of 12oz. soft drinks -- 24 cans in each case)
50 lbs. (for example, 3 cases of 12oz. soft drinks -- 24 cans in each case)
70 lbs. (for example, 4 cases of 12oz. soft drinks -- 24 cans in each case)
10. What is your present activity level?
Check the level of activity listed below that best describes how often you participate in each of the activities:
Activity

Never/Rarely

Occasionally

Frequently

0 to 2 times per year

1 to 2 times per month

Once per week or more

Walk 2 miles continuously

Never/Rarely_________ Occasionally _________

Frequently _________

Run 2 miles continuously

Never/Rarely_________ Occasionally _________

Frequently _________

Weight training

Never/Rarely_________ Occasionally _________

Frequently _________

General fitness activities at gym

Never/Rarely_________ Occasionally _________

Frequently _________

Basketball

Never/Rarely_________ Occasionally _________

Frequently _________

Tennis, racquetball, badminton

Never/Rarely_________ Occasionally _________

Frequently _________

Soccer

Never/Rarely_________ Occasionally _________

Frequently _________

Gardening

Never/Rarely_________ Occasionally _________

Frequently _________

Golf

Never/Rarely_________ Occasionally _________

Frequently _________

Never/Rarely_________ Occasionally _________

Frequently _________

Never/Rarely_________ Occasionally _________

Frequently _________

Winter sports (cross country skiing,
downhill skiing, ice skating)

Other (list):

CANDIDATE SIGNS HERE
I certify that I have reviewed the foregoing information supplied by me and it is true and complete to the best of my
knowledge.
or clinics to furnish the Government a complete
transcript
g I authorize any
y of the doctors, hospitals,
p
p
p of my
y
medical record for purposes of processing my application. I have read the privacy statement at the beginning of this
questionnaire and understand that falsification of information on Government forms is punishable by fine and/or
imprisonment.
Sign your name and enter today's date in the space provided below:

REQUIRED
Candidate Signature

Date (mm/dd/yyyy)

FACILITY MEDICAL EXAMINER SIGNS HERE
Print Name:

REQUIRED
Signature:

REQUIRED
Facility Medical Examiner

Date (mm/dd/yyyy)

Print Name:

Signature:

Facility Medical Co-Signature (If required)

TSA Form 1130A-1, 12/09 [File: 1100.0.1]
OMB control number 1652 - 0032; Expiration Date:03/13/2012

Date (mm/dd/yyyy)

Page 6 of 6

Candidate Initials _________