Form TSA Form 417 TSA Form 417 Screening Assistance Request

OMB control number 1652-xxxx
Exp. XX/XX/XX

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
SCREENING ASSISTANCE REQUEST

Instructions: This form is to be completed in accordance with OD-400-45-4B, Establishment and Functions of the
Transportation Security Administration Wounded Warrior/Military Severely Injured Joint Support Operations (MSIJSOC) for
service members who are verified and registered with an official U.S. military service/component of the Wounded Warrior
Program and their traveling companion(s) who are eligible to receive expedited screening. The MSIJSOC will email the
completed form to the respective FSD-designated employee at the appropriate airport to assist the Wounded Warrior and
traveling companions.
Section I. Administrative Information
am
Date of Request

Time

pm

Internal Control Number

TSA Liaison

Vetted By

Section II. Veteran Information
Name

Phone Number

Branch

Rank

POC Mobile
Phone Number

Email

Section III. Traveling Family Members
Number of Adults (other than the service member)

Number of Children
Itinerary Provided

Case Manager Name

Phone Number

Yes

No

Section IV. Traveling Family Members/Companions (complete if additional passengers are traveling)
Name

Name

Name

Name

Name

Name

Section V. Flight Information
Departure Airport

am
Date

Airline and Flight Number

Time

Arriving Airport

am
Date

Time

Date

Time

Date

Time

Departure Airport

Airline and Flight Number

pm

pm
am

Arriving Airport

pm
am
pm

Previous editions of this form are obsolete
TSA Form 417 (9/17) rev. [File: 5000.26]

Page 1 of 2

SCREENING ASSISTANCE REQUEST

OMB control number 1652-xxxx
Exp. XX/XX/XX

Departure Airport

Airline and Flight Number

am
Date

Time

Date

Time

Date

Time

Arriving Airport

am

Departure Airport

Airline and Flight Number

pm
am

Arriving Airport

pm
am

Date

Time

Date

Time

Departure Airport

Airline and Flight Number

pm

pm

am

Arriving Airport

pm

am
Date

Time

pm

Section VI. Specialist Traveling Needs

Section VII. MSIJSOC TSA Liaison Contact Information
Emailed (preferred contact method): [email protected]

Phone Number: 1-888-262-2396 or 703-603-0503

Fax Number: 703-603-1558
Privacy Act Statement: AUTHORITY: 49 U.S.C. § 114(f)(15); 49 U.S.C. § 44927. PRINCIPAL PURPOSE(S): This information is used to
coordinate and provide airport security screening assistance to eligible travelers. ROUTINE USE(S): This information may be shared in
accordance with the Privacy Act of 1974, 5 U.S.C. § 552(a), or for routine uses identified in the TSA system of records, DHS/TSA-001,
Transportation Security Enforcement Record System. DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the
requested information may prevent TSA from providing assistance through airport security screenings to eligible travelers.
Paperwork Reduction Act Statement: The collection involves the submission of travel information to Transportation Security Administration to
provide wounded warrior, severely injured military personnel, and certain other travelers with assistance through the airport security screening
process. This is a voluntary collection. It is estimated that the total average burden per response associated with this collection 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 assigned to this collection is OMB 1652-XXXX, which expires XX/XX/XXXX. Send
comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to
TSA PRA Officer, 601 S. 12th Street, Arlington, VA 20598-6011. ATTN: PRA 1652-XXXX.

TSA Form 417 (9/17) rev. [File: 5000.26]

Previous editions of this form are obsolete

Page 2 of 2