Form TSA Form 1915 TSA Form 1915 CMSDT Program Attendance Roster

DEPARTMENT OF HOMELAND SECURITY

OMB Control No.1652-0028
Expires 7/31/2018

Transportation Security Administration
CMSDT PROGRAM ATTENDANCE ROSTER

INSTRUCTIONS: The Crew Member Self Defense (CMSD) Trainer shall complete Section I. with the field office location and date of training.
Section II. shall be completed by the trainer or the trainee with the trainee name, airline affiliation, airline ID number and contact information.
The CMSD Trainer will verify if the training has been completed, if a certification was received and sign and date Section III.
SECTION I. Training Information
Field Office Location

Date of Training

SECTION II. Roster Information
TO BE COMPLETED
BY TRAINER

TO BE COMPLETED BY TRAINER OR TRAINEE
Name

Airline
Affiliation

Airline
ID Number

Contact Information
(Mailing Address/Email/Phone Number)

Training
Complete

Certification
Received
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

SECTION III. Signatures
Instructor Signature

Date

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f). PRINCIPAL PURPOSE(S): The information will be used to verify attendance at the Crew
Member Self Defense Training Program, whether or not the training was completed and if a certification was received. ROUTINE USE(S): This information may
be shared with educational institutions or training facilities for purposes of enrollment and verification of attendance and performance, or for routine uses identified
in the Department of Homeland Security's system of records notice, DHS/ALL-003 Department of Homeland Security General Training Records. DISCLOSURE:
Voluntary; failure to furnish the requested information may result in an inability to verify your attendance at the Crew Member Self Defense Training Program,
whether or not the training was completed and if a certification was received.
PAPERWORK REDUCTION ACT STATEMENT: Through this voluntary collection of information, TSA is gathering information about you to confirm your
attendance at TSA's crew member self-defense training course. The public burden for this collection of information is estimated to be five 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 currently valid OMB control number. The
OMB control number assigned to this collection is 1652-0028, which expires 07/31/2018. 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
1652-0028.

Previous editions of this form are obsolete.
TSA Form 1915 (3/18) rev. [File: 3500.13]

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