Information Collection

FAMS Mental Health Certification

IC 46519 under ICR 201601-1652-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1164 FAMS Mental Health Certification	Form
TSA 1164 Mental Health Certification TSA 1164 MHC_01272016.doc	Form

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	TSA 1164	Mental Health Certification	TSA 1164 MHC_01272016.doc		Yes	Yes	Fillable Fileable

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: 600

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	0	600
Annual IC Time Burden (Hours)	600	0	600
Annual IC Cost Burden (Dollars)	0	-270	270

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.