Transportation Security Officer Medical Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TSA Form 1130A-1 TSO Medical Questionnaire	Form and Instruction	Modified	Available
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 Tuberculosis 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 Orthopedic Further Evaluation	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
OPMGOVT-5.pdf	Supplementary Document	Uploaded 2016-05-04	Available
OPMGOVT-10 System.pdf	Supplementary Document	Uploaded 2016-05-04	Available
SORN DHSTSA - 022 71 FR 40530 (7172006).pdf	Supplementary Document	Uploaded 2016-05-04	Available
1652-0032 TSO Med Qaire 30DN 04.01.2016.pdf	Supplementary Document	Uploaded 2016-05-04	Available
1652-0032 TSO Med Qaire 60DN 04.01.2016.pdf	Supplementary Document	Uploaded 2016-05-04	Available
1652-0032 TSO Med Qaire SS_06.23.2016.docx	Supporting Statement A	Uploaded 2016-06-23	Available
RELEASE - TSA_Form_1130A-3_FINAL_01.08.10.docx	Supplementary Document	Uploaded 2010-01-22	Available
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	Repair queued
44 USC 44935.doc	Supplementary Document	Uploaded 2006-09-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191700	TSO Medical Questionnaire and Evaluation	Form and Instruction	Modified	TSO Medical Questionnaire
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	Tuberculosis 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	Orthopedic Further Evaluation
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

ICR Details

OMB Control No: 1652-0032	ICR Reference No: 201603-1652-002
Status: Historical Active	Previous ICR Reference No: 201301-1652-006
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: Approved without change	Conclusion Date: 07/01/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/31/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved	06/30/2016
Responses	29,017	0	26,565
Time Burden (Hours)	14,071	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 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:
	80 FR 73806	11/25/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 14472	03/17/2016
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-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, 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	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 ,   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

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ICR Summary of Burden

table that charts list 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	29,017	26,565	0	0	2,452	0
Annual Time Burden (Hours)	14,071	12,912	0	0	1,159	0
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: There are no changes to the information being collected. However, the burden has increased due to the use of better estimates provided by the program office. Due to improved efficiencies in the program office, the cost to TSA has decreased. For example, either the provider or the candidate will ship the FE forms when shipping packages, but not both. Therefore, the cost is per candidate delivery to the contractor, as both the candidate and the provider will complete and review the same form for shipment instead of separately as done in the past.

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Annual Cost to Federal Government: $503,074

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: 03/31/2016

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