Information Collection

TSO Medical Questionnaire and Evaluation

IC 191700 under ICR 201603-1652-002 · OMB 1652-0032.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0032 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TSA Form 1130B-2 TSO Medical Questionnaire and Evaluation	Form and Instruction
TSA Form 1130B-1 Cancer Further Evaluation CANCER - TSA_Form_1130B-1_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-2 Cardiac Further Evaluation CARDIAC - TSA_Form_1130B-2_FINAL_01.08.10.docx	Form and Instruction
TSA Form 1130B-3 Cardiac Surgery Further Evaluation CARDIAC SURGERY- TSA_Form_1130B-3_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-4 Diabetes Further Evaluation DIABETES - TSA_ Form_1130B-4_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-5 Drug Use Further Evaluation DRUG USE - TSA_Form_1130B-5_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-6 General Medical Further Evaluation GENERAL MED - TSA_Form_1130B-6_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-7 Hearing Further Evaluation HEARING - TSA_Form_1130B-7_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-8 Hepatitis Further Evaluation HEPATITIS - TSA_Form_1130B-8_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-9 Hernia Further Evaluation HERNIA - TSA_Form_1130B-9_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-10 HIV Further Evaluation HIV - TSA_Form_1130B-10_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-11 Pacemaker Further Evaluation PACEMAKER - TSA_Form_1130B-11_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-12 Mental Health Further Evaluation MENTAL HEALTH - TSA_Form_1130B-12_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-13 Orthopedic Further Evaluation ORTHOPEDIC - TSA_Form_1130B-13_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-14 Palmar Further Evaluation PALMAR - TSA_Form_1130B-14_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-15 Respiratory Further Evaluation RESPIRATORY - TSA_Form_1130B-15_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-16 Seizure Further Evaluation SEIZURE - TSA_Form_1130B-16_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-17 Tuberculosis Further Evaluation TB - TSA_Form_1130B-17_ FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-18 Vision Further Evaluation VISION - TSA_Form_1130B-18_FINAL_01 08 10.docx	Form and Instruction
TSA Form 1130B-19 Vital Signs Further Evaluation VITAL SIGNS - TSA_Form_1130B-19_FINAL_ 01 08 10.docx	Form and Instruction
TSA Form 1130A-1 TSO Medical Questionnaire TSA_Form_1130A-1_FINAL_03_31_2016.pdf	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

TSO Medical Questionnaire and Evaluation

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	TSA Form 1130B-2	Cardiac Further Evaluation	CARDIAC - TSA_Form_1130B-2_FINAL_01.08.10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-3	Cardiac Surgery Further Evaluation	CARDIAC SURGERY- TSA_Form_1130B-3_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-4	Diabetes Further Evaluation	DIABETES - TSA_ Form_1130B-4_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-5	Drug Use Further Evaluation	DRUG USE - TSA_Form_1130B-5_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-6	General Medical Further Evaluation	GENERAL MED - TSA_Form_1130B-6_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-7	Hearing Further Evaluation	HEARING - TSA_Form_1130B-7_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-8	Hepatitis Further Evaluation	HEPATITIS - TSA_Form_1130B-8_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-9	Hernia Further Evaluation	HERNIA - TSA_Form_1130B-9_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-10	HIV Further Evaluation	HIV - TSA_Form_1130B-10_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-11	Pacemaker Further Evaluation	PACEMAKER - TSA_Form_1130B-11_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-12	Mental Health Further Evaluation	MENTAL HEALTH - TSA_Form_1130B-12_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-13	Orthopedic Further Evaluation	ORTHOPEDIC - TSA_Form_1130B-13_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-14	Palmar Further Evaluation	PALMAR - TSA_Form_1130B-14_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-15	Respiratory Further Evaluation	RESPIRATORY - TSA_Form_1130B-15_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-16	Seizure Further Evaluation	SEIZURE - TSA_Form_1130B-16_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-17	Tuberculosis Further Evaluation	TB - TSA_Form_1130B-17_ FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-18	Vision Further Evaluation	VISION - TSA_Form_1130B-18_FINAL_01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130B-19	Vital Signs Further Evaluation	VITAL SIGNS - TSA_Form_1130B-19_FINAL_ 01 08 10.docx	No	Paper Only
Form and Instruction	TSA Form 1130A-1	TSO Medical Questionnaire	TSA_Form_1130A-1_FINAL_03_31_2016.pdf	No	Paper Only
Form and Instruction	TSA Form 1130B-1	Cancer Further Evaluation	CANCER - TSA_Form_1130B-1_FINAL_01 08 10.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 29,017

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	29,017	2,452	26,565
Annual IC Time Burden (Hours)	14,071	1,159	12,912
Annual IC Cost Burden (Dollars)	0	0	0

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table that charts IC Documents
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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.