TSA Form 1130B-12 Mental Health Further Evaluation

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OMB# 1

Mental Health Evaluation

andidate Name: Last 4 Digits of SSN: __ __ __ __

MEDICAL CONDITION:

This candidate is under consideration for a position as a Transportation Security Officer (TSO) position at the Transportation Security Administration (TSA). His/her pre-employment medical screening, including a medical history review on ____________________________, revealed the following: ______________________________________________

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Paperwork Reduction 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 5 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. The control number for this collection is OMB control number 1652-0032, which expires 3/31/2016.

CANDIDATE SECTION:

• Candidate must complete Candidate section, including signature

• Candidate should bring past records from Mental Health provider(s) to this evaluation

• Candidate will not receive further consideration in the TSO job application process if CHS does not receive ALL requested paperwork within 90 days of the candidate being placed on Further Evaluation for the position

1. What is/was your diagnosis? _________________________When were you diagnosed? ___________________

2. What symptoms were you having at the time you were diagnosed? _______________________________________

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3. What medication(s), if any, have you taken in the past for this condition? (Approximate dates started and stopped.)

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4. What symptoms have come back over time? ________________________________________________________

5. What situations brought on the symptoms you were having? ____________________________________________________________________________________________

6. Have you ever been hospitalized for this condition?  No  Yes If yes, when? ___________(Please provide

discharge summary for all/any psychiatric hospitalizations.)

7. Have you been in counseling/treatment for this condition?  No  Yes If yes, when? __________________

8. Have you ever missed days of work/school due to this condition?  No  Yes

9. What medication(s), if any, are you presently taking for this condition? (Approximate date started) ____________________________________________________________________________________________

____________________________________________________________________________________________

9. Describe any additional information regarding any of the above questions. ____________________________________________________________________________________________

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Any expenses incurred remain your responsibility and will not be reimbursed by CHS or TSA

Candidate Signature: _______________________________________ Date: ____________________________

Fax all pages of this form, supporting documentation, and recent diagnostic test results including

ALL PROGRESS NOTES WITHIN THE LAST 12 MONTHS to CHS. If unable to fax please call 866-416-5928

Mental Health Evaluation

Candidate Name: Last 4 Digits of SSN: __ __ __ __

HEALTH CARE PROVIDER SECTION:

• Health Care Provider must verify candidate’s identification with a government issued photo ID, e.g., driver’s license or passport

• Health Care Provider must complete Health Care Provider section, including signature, printed name, and contact number

• Health Care Provider must review, sign and date the attached “Transportation Security Officer (TSO) Job Overview” and determine candidate’s ability to perform this job in relation to the condition indicated on Page 1.

The requested evaluation is for a candidate applying for a Security-Sensitive Transportation Security Officer position.  The position requirements are listed on Page 5 and may include long hours, irregular shifts, irregular meals and breaks, and interaction with numerous travelers in stressful and less-than-optimal conditions.  The position requires maximum alertness and ability to react promptly to emergencies.

History that initiated this Mental Health Further Evaluation________________________________________________________________________

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1. What mental disorder(s) have been identified for this candidate? List DSM IV Code (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition), and date(s) for each diagnosis. Also list any current medication(s).

Date(s) Diagnosis DSM IV Code Medications

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2. What is the current working diagnosis? __________________________________Prognosis? ________________________________________

Current Medication(s) Date Started Dose Frequency

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3. Has the candidate ever been hospitalized for this condition?  No  Yes If yes, when? _____________ (Please provide discharge summary for all/any psychiatric hospitalizations.)

4. Has the candidate been compliant with the treatment plan?  No  Yes  Not applicable (NA)

5. How long has the candidate been stable with the current medication(s) and treatment? _______________________  NA

6. In your opinion and based on your diagnosis, would this candidate reliably remain vigilant and alert, and react to emergencies in a calm and prompt manner when working in a stressful and demanding environment?  No  Yes

Please explain No/Yes ________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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7. In your opinion and based on your diagnosis, would a stressful work environment be detrimental to the candidate’s mental health?

 No  Yes Please explain No/Yes ___________________________________________________________________________________

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8. Additional comments (attach additional pages if needed): _____________________________________________________________________

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Mental Health Evaluation

Candidate Name: Last 4 Digits of SSN:

HEALTH CARE PROVIDER SECTION (cont.):

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Mental Health Evaluation

uring your current mental health assessment of this candidate, please address the questions listed below, explore any issues identified, and document any additional questions/concerns or diagnoses for a complete mental health evaluation. Please use any additional measures you feel appropriate to determine the current mental status of the candidate and provide a report of the results.

1. How are you doing today?

2. Are you generally in a good mood?

3. What do you do in your present job? How have you been doing at work?

4. What type of job performance evaluations have you had?

5. During the past two weeks have you felt worried, nervous, or stressed?

6. Have you ever had a panic attack?

7. Have you had any problems with concentrating on work activities or remembering things you need to do?

8. How have you been sleeping lately?

   1. Do you get at least five hours sleep most nights (days)?

   2. On average, how long does it take you to fall asleep?

   3. Do you feel well rested upon awakening?

9. What are your interests outside of work?

A. During the past months, have you maintained interest and pleasures in this activity?

10. Have you ever had trouble getting along with co-workers or supervisors?

11. During the past two weeks, have you felt down, depressed, or hopeless?

12. Do you ever have headaches? How often do they occur?

13. What medications are you currently taking and why?

14. Were you ever suspended or expelled from school?

15. Do you drink alcohol?

    1. How frequently?

B. Have you ever had an alcohol related driving offense?

13. Have you ever had any health-related, job-related, marital, or other social related problems as a result of your drug or alcohol use?

14. Have you ever been arrested?

    1. When were you arrested?

    2. What were the circumstances?

    3. Was any of your arrests alcohol or drug related?

15. Have you ever been fired from a job? If so, what were the circumstances?

16. When were you last involved in a physical fight?

17. How many close relationships do you have?

18. Who did you “hang out” with in high school?

I have addressed these questions in my evaluation.

Mental Health Care Specialist Signature: ____________________________ Date: ______________

Credentials/Title : _____________________________________________________________________________

Mental Health Evaluation

Candidate Name: Last 4 Digits of SSN:

HEALTH CARE PROVIDER SECTION (cont.):

Please document observable characteristics present during assessment.

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Please Provide:

Axis I _________________________________________________________________________________________

Axis II _________________________________________________________________________________________

Axis III _________________________________________________________________________________________

Axis IV __________________________________________________________________________________________

Axis V __________________________________________________________________________________________

Please provide a copy of your office records from the current evaluation

and any others within the last 12 months.

Mental Health Care Specialist Signature: _________________________________ Date: _____________________

Printed Name: ___________________________________ Credential / Title: ________________________________

Phone Number: (__ __ __) __ __ __ - __ __ __ __ FAX Number: (__ __ __) __ __ __ ___ __ __ __

Fax all pages of this form, supporting documentation, and recent diagnostic test results including

ALL PROGRESS NOTES WITHIN THE LAST 12 MONTHS to CHS. If unable to fax please call 866-416-5928

FAX 703-288-5495

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Mental Health Evaluation

andidate Name: Last 4 Digits of SSN: __ __ __ __

Transportation Security Officer (TSO) Job Overview

from Vacancy Announcement on www.usajobs.gov

1. A TSO must be willing and able to:

• Repeatedly lift and carry up to 70 pounds;

• Continuously stand for anywhere between one (1) to four (4) hours without a break to carry out screening functions;

• Walk up to two (2) miles during a shift;

• Continuously and effectively interact with the public, giving directions and responding to inquiries in a reasonable tone and manner;

• Maintain focus and awareness and work within a stressful environment which includes noise from alarms, machinery, and people, distractions, time pressure, disruptive and angry passengers, and the requirement to identify and locate potentially life threatening devices and devices intended on creating massive destruction; and

• Make effective decisions in both crisis and routine situations.

2. TSO medical standards include but are not limited to:

• Visual ability including two functioning eyes with:

• Distance vision correctable to 20/30 or better in the best eye and 20/100 or better in the worse eye;

• Near vision correctable to 20/40 or better binocular;

• Color perception (e.g., red, green, blue, yellow, orange, purple, brown, black, white, gray). Note: color filters (e.g., contact lenses) for enhancing color discrimination are prohibited;

• Hearing (corrected or uncorrected) as measured by audiometry cannot exceed:

• an average hearing loss of 25 decibels (ANSI) at 500, 1000, 2000 and 3000 Hz in each ear, and

• single reading of 45 decibels at 4000 and 6000 Hz in each ear;

• Adequate joint mobility, dexterity and range of motion, strength, and stability to repeatedly lift and carry up to 70 pounds; and

• Blood pressure not to exceed 140 / 90.

Physician Review

Based on my findings and opinions presented in the Health Care Provider Section of this form, this candidate:

• Is capable of meeting the above job requirements safely, efficiently and effectively with respect to my medical specialty and this candidate’s medical condition and/or diagnosis noted on Page 2.

• Is NOT capable of meeting the above job requirements safely, efficiently and effectively with respect to my medical specialty and this candidate’s medical condition and/or diagnosis noted on Page 2.

Specify reason(s) and provide explanation based on the above reference number(s): ___________________________________________________________________________________

___________________________________________________________________________________

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Mental Health Care Specialist Signature: ______________________________________ Date: _____________

Please Print Name: _____________________________________ Medical Specialty: ______________________

Phone Number: (__ __ __) __ __ __ - __ __ __ __ FAX Number: (__ __ __) __ __ __ - __ __ __ __

Note: All data provided by the candidate’s physician(s) are part of an initial medical evaluation. The final determination of medical suitability will be made by Transportation Security Administration medical staff based on the aggregate of all medical data acquired.

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;

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TSA Form 1130B-12, 12/09 [File: 1100.0.1] OMB control number 1652 - 0032; Expiration Date: 03/31/2016