Form TSA Form 1130A-1 TSA Form 1130A-1 TSO Medical Questionnaire

OMB 1652-0032

Exp. 7/31/2019

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

TRANSPORTATION SECURITY OFFICER

MEDICAL QUESTIONNAIRE

INSTRUCTIONS: It is required that you personally complete each question or response in this questionnaire. After completing each page, record your initials in the space provided at the bottom of each page and print and sign your name on the last page. Your responses will be reviewed with you by a medical professional.

It is recommended that you review the TSO Medical Guidelines prior to taking the medical assessment. The medical guidelines can be found at https://hraccess.tsa.dhs.gov/hraccess/pdf/TSO_Medical_Guidelines.pdf. Consider bringing medical records/documentation regarding any chronic diseases or medical conditions, such as recent lab reports or stress test results to your medical exam appointment. For purposes of this examination, please do not include any genetic information, including family medical history or the results of any genetic testing, with any medical records/documentation you provide. NOTE TO MEDICAL EXAMINER: Please do not collect any genetic information provided by the examinee.

SECTION I. DEMOGRAPHIC INFORMATION Candidate Initials _________

Name (Print):

LAST 4 OF SSN: XXX – XX - ______________

SEX: Male ________ Female ________

Address:

City, State, Zip:

Primary Phone: ( ) –

Date of Birth (mm/dd/yyyy): _______________________

Secondary Phone: ( ) –

Other Phone: : ( ) –

Height: Feet ______ Inches ______ Weight _______

Best Time to Call:

SECTION II. GENERAL INFORMATION

1. Have you been refused employment, dismissed from a job, or unable to stay in school due to any 1. YES ____ NO ____

medical condition or excessive absenteeism?

If YES, please list each medical condition and the year of the refusal/dismissal:

1. MO/YR ________________

2. MO/YR ________________

3. MO/YR ________________

_{2. Have you had any operations and/or medical procedures? 2.} YES ____ NO ____

If YES, describe and indicate date:

1. MO/YR ________________

2. MO/YR ________________

3. MO/YR ________________

3. Have you had a visit to a clinic, physician, chiropractor, ER, urgent care, outpatient facility, 3. YES _____ NO _____

physical therapist, healer, acupuncturist, or any other practitioner within the past year?

If YES, specify condition and healthcare provider consulted, and indicate date:

1. MO/YR ________________

2. MO/YR ________________

3. MO/YR ________________

_{EXAMINER COMMENTS – GENERAL INFORMATION:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION II. (continued) Candidate Initials _________

4. Are you currently taking any prescription medications? 4. YES ____ NO ____

If YES, complete box below. If medication is “as needed” specify approximate frequency. Use back of paper as needed.

NAME OF MEDICATION	REASON FOR MEDICATION	DOSE	Frequency: How often do you take each (daily, nightly, etc.)?	DATE of LAST DOSE

5. Are you currently taking any non- prescription OTC medications/herbs/supplements? 5. YES ____ NO ____

If YES, complete box below. If medication is “as needed” specify approximate frequency. Use back of paper as needed.

NAME OF MEDICATION	REASON FOR MEDICATION	DOSE	Frequency: How often do you take each (daily, nightly, etc.)?	DATE of LAST DOSE

_{EXAMINER COMMENTS – GENERAL INFORMATION:}

_{Examiner MUST enter a comment on all positive history / “yes” answers. Ensure all sections of medication tables are complete.}

SECTION III. VISION AND HEARING

_{6. Do you have known uncorrectable vision loss or a total loss of vision in either eye?................. 6. YES _____ NO______}

_If YES, indicate date of onset:………………………………………………Date: MO/YR _______

_{7. Have you had any type of refractive eye surgery such as LASIK, PRK, etc.?.............................. 7. YES _____ NO______}

_{If YES, answer below:}

1. Type of surgery: Date: MO/YR ___________

2. Do you have any dryness that affects your vision?............................. YES _____ NO______

3. Do you use steroid eye drops? ………………………………………….. YES _____ NO______

_{8. Do you use a hearing aid for either ear?......……………………………………………………….. 8. YES _____ NO______}

_{EXAMINER COMMENTS – VISION and HEARING:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION IV. RESPIRATORY Candidate Initials ______

_{9. Do you have asthma?................................................................................................................ 9. YES _____ NO______}

_{10. Do you have chronic obstructive pulmonary disease (COPD)?.................................................. 10. YES _____ NO______}

_{11. Do you have blood in sputum when coughing?.......................................................................... 11. YES _____ NO______}

_{12. Have you EVER had active tuberculosis (not just a positive skin test)? …………………………12. YES NO}

_{If YES, answer the questions below:}

1. _{When was your last Chest X-Ray?........................................................... Date:} MO/YR ________

2. _{When were you treated?........................................................................... Date:} MO/YR ________

3. _{How long was your treatment? ____________________________________________________}

_{13. Have you ever had any other lung disease? ………………………………………………………. 13. YES _____ NO______}

_{If YES, specify disease: ________________________________________________________________}

_{EXAMINER COMMENTS – RESPIRATORY:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION V. CARDIOVASCULAR

Have you ever had or experienced any of the following?

14. Hypertension? ………………………………………………………………………………………….._{14. YES _____ NO______}

If YES, answer the questions below and Go to APPENDIX A at the end of this document to provide complete information:

1. Have you had a treadmill exercise stress test? _{…………………………… YES _____ NO______}

If YES, date of most recent? ………………… MO/YR

_{Was it normal? ………………………………… YES NO Don’t know _______}

_{What METS did you reach? ……..……………. ___________________ Don’t know _______}

2. Have you had any complications of hypertension, such as, stroke, coronary artery disease, left ventricular hypertrophy, atrial fibrillation, heart failure, nephropathy, retinopathy, or aortic aneurysm? _{YES __ NO _____}

_{List the complication(s): _____________________________________________________________}

_{Complete APPENDIX A at the end of this document.}

_{15. Coronary artery disease, heart attack, open heart surgery, st}ent, or angioplasty? …………….._{15. YES _____ NO______}

_{If YES, answer the questions below:}

1. _{Indicate MO/YR or Not applicable (NA):}

_{Heart attack ____________ Open heart surgery ____________ Stent or angioplasty ____________}

2. Have you had a treadmill exercise stress test with imaging?................... _{YES ______ NO ______}

Date of most recent? ………………………… MO/YR

_{Was it normal? ………………………………… YES NO Don’t know _______}

_{What METS did you reach? ...…………………_____ ________ Don’t know _______}

3. Do you have chest pain with exertion or activity? ………………………... _{YES ______ NO ______}

4. Are your risk factors being treated (smoking, hypertension, cholesterol, obesity, etc.)? _{YES _____ NO _____}

5. When was your last heart medication change? ……………………….. MO/YR __________

6. Have you been compliant with treatment? ………………………………... _{YES NO ______}

SECTION V. (continued) Candidate Initials ______

16. Heart failure? ………....................................................................................................................._{16. YES _____ NO______}

If YES, answer the question below:

1. Have you had an echocardiogram, or stress echocardiogram? ……….. _{YES _____ NO _____}

If YES, indicate the ejection fraction if known: ……………… % _{Don’t know ________}

_{17. Cardiomyopathy? …………………}…………………………………………………………………….._{17. YES _____ NO______}

18. Atrial fibrillation, atrial flutter, supraventricular tachycardia, Wolff-Parkinson-White Syndrome, or ventricular tachycardia?

_{………………………………………………………………………………………………………………..}………….._{18. YES _____ NO______}

If YES, answer the questions below:

1. Did you have an ablation? .………………………………………………… _{YES _____ NO _____}

Date(s) of ablation? ………………………………………………………….. MO/YR ________

Was it successful? …………………………………………………………… _{YES _____ NO _____}

2. Have you had an echocardiogram, or stress echocardiogram? ……….. _{YES _____ NO _____}

If YES, indicate the ejection fraction if known: ………………….. % _{Don’t know _____}

3. Have you had a treadmill exercise stress test with imaging? ……………. _{YES _____ NO _____}

Date of most recent? …………………………………………………….. MO/YR __________

Was it normal? ………………………………………… _{YES NO Don’t know ________}

_{What METS did you reach? ………………………….. _____ ________ Don’t know ________}

_{19. Ventricular fibrillation? …………………}………………………………………………………………._{19. YES _____ NO _____}

_{20. Unexplained syncope (fainting or passing ou}t)? ……………………………………………………._{20. YES _____ NO _____}

If YES, date of last occurrence: …………………………………............................ MO/YR ________________

21. Pacemaker? …………………………………………………………………………………………….._{21. YES _____ NO _____}

22. Valvular heart disease? ………………………………………………………………………………..._{22. YES _____ NO _____}

If YES, specify type: _______________________________________________________________________

23. Automatic implantable cardiac defibrillator (AICD)?..……………………………………………….._{23. YES _____ NO _____}

24. Peripheral vascular disease that causes pain with walking? ………………………………………._{24. YES _____ NO _____}

25. Thoracic or abdominal aortic aneurysm? …...………………………………………………………..._{25. YES _____ NO _____}

26. Other cardiac condition(s) not previously mentioned? ………………………………………………_{26. YES _____ NO _____}

Please explain: ____________________________________________________________________________

_{EXAMINER COMMENTS – CARDIOVASCULAR:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

_{If history of heart failure or cardiomyopathy, what is the NYHA classification, I II III IV:}

SECTION VI. ABDOMINAL ORGANS and RENAL Candidate Initials ______

27. Have you had or do you currently have a hernia? ……………………………………………………_{27. YES _____ NO _____}

If YES, answer questions below:

1. Circle type: inguinal ventral umbilical femoral

2. Has it been repaired? ………………………………………………………. _{YES _____ NO _____}

3. Do you have pain, restrictions, or limitations? ………………………….. _{YES _____ NO _____}

If YES, specify limitations/restrictions: _____________________________________________

28. Do you have chronic kidney disease (CKD)? ……………………………………………………......._{28. YES _____ NO _____}

If YES, answer the questions below:

a. What is the stage? (circle response) 1 2 3 4 5 Don’t Know ______

b. What is your most recent GFR? _____________mL/min MO/YR ___________ Don’t Know ______

29. Are you being treated with hemodialysis or peritoneal dialysis? ….………………………………. _{29. YES _____ NO _____}

_{EXAMINER COMMENTS – ABDOMINAL ORGANS and RENAL:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION VII. MUSCULOSKELETAL

Have you ever had or experienced any of the following?

30. Amputation or congenitally absent body part?.............................................................................._{30. YES _____ NO _____}

If YES, answer below:

1. Specify body part: _________________________________________________________

2. Do you use any prosthesis? ……………………………………………. _{YES _____ NO _____}

31. Do you use any ambulatory aids (crutches, cane, walker, etc.)? …………………………………..31_{. YES _____ NO _____}

If YES, specify: _______________________________________________________________

32. Upper extremity condition (hand, wrist, forearm, elbow, upper arm, shoulder)? …………………._{32. YES _____ NO _____}

If YES, specify: ______________________________________________________________

33. Lower extremity condition (foot, ankle, lower leg, knee, upper leg, hip)? ………………………… _{33. YES _____ NO _____}

If YES, specify: ______________________________________________________________

34. Spine condition (back, neck, surgery)? ……………………………………………………………….._{34. YES _____ NO _____}

If YES, specify: ______________________________________________________________

35. Joint replacement surgery? ……………………………………………………………………………._{35. YES _____ NO _____}

If YES, provide details and dates: MO/YR _________

_{EXAMINER COMMENTS – MUSCULOSKELETAL:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.} If examinee has current and temporary physical restrictions (lift, squat, bend, reach overhead, walk, stand, etc.) document how long the restrictions are expected to last; if not known please state.

SECTION VIII. NEUROLOGICAL Candidate Initials ______

Have you ever had or experienced any of the following:

36. Cerebrovascular accident (CVA, stroke, brain bleed, or TIA)? …………………………………….._{36. YES _____ NO _____}

If YES, answer below:

1. Specify type and date: MO/YR _______

2. Do you have any residual physical, mental, or emotional impairments or limitations? _{YES _____ NO _____}

If YES, explain: _______________________________________________________

37. Seizures?…………………………………………………………………………………………………._{37. YES _____ NO _____}

_{If YES, answer the questions below:}

1. Do you have epilepsy?.............................................................................. _{YES _____ NO _____}

2. What causes your seizures? Don’t Know ________

3. Date of last seizure? ……………………………………………………. MO/YR ________

4. Date of last evaluation by a neurologist? …………………………….. MO/YR ________

38. Vertigo? …………………………………………………………………………………………………. _{38. YES _____ NO _____}

If YES, specify date of last occurrence: …………………………………... MO/YR _______

39. Meniere’s disease? …………………………………………………………………………………….. 39_{. YES _____ NO _____}

40. Paralysis of a limb? …………………………………………………………………………………….. 40_{. YES _____ NO _____}

41. Complete loss of touch sensation in upper extremity? ……………………………………………... 41_{. YES _____ NO _____}

42. Cognitive impairment (ongoing memory loss, dementia)? ………..………………………………... _{42. YES _____ NO _____}

43. Malignancy of the spinal cord or brain? ……………………………………………………………..…_{43. YES _____ NO _____}

44. Amyotrophic lateral sclerosis? ………………………………………………………………………… _{44. YES _____ NO _____}

45. Multiple sclerosis? ……………………………………………………………………………………….._{45. YES _____ NO _____}

If YES, answer questions below:

1. Specify date of diagnosis: …………………………………………….. MO/YR _______

2. Specify date of last relapse: ………………………………………….. MO/YR _______

3. Do you have a mood disorder? ……..……………………………….. _{YES _____ NO _____}

46. Parkinson’s? ……………………………………………………………………………………………...46_{. YES _____ NO _____}

_{47. Other neurologic disorder not previously} noted? ……………………………………………………...47_{. YES _____ NO _____}

If YES, specify: _______________________________________________________________________________

_{EXAMINER COMMENTS –NEUROLOGICAL:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION IX. ENDOCRINE Candidate Initials ______

_{48. Do you have diabetes? ……………}…………………………………………………………………….48_{. YES _____ NO _____}

If YES, answer questions (a) through (o) below and Go to APPENDIX A at the end of this document to provide complete information:

1. Are you compliant with your prescribed treatment? ………………………. _{YES _____ NO _____}

2. Have you had an episode(s) of hypoglycemia requiring the help of others in the past three years?

_{YES _____ NO _____}

If YES, specify details and dates:

1. ____________________________________________________________________

2. ____________________________________________________________________

3. Have you had diabetic ketoacidosis in the past 12 months? ………..…… _{YES _____ NO _____}

4. What was your last hemoglobin A1c? … % Don’t know ____________

5. When was your last hemoglobin A1c? ……………….….……………….. MO/YR ____________

6. Have you completed diabetes education? …………………………………. _{YES _____ NO _____}

7. Do you self-monitor your blood glucose? …………………………………...._{YES _____ NO _____}

8. Do you have lightheadedness with standing? …..………….………………._{YES _____ NO _____}

9. Do you have peripheral neuropathy that interferes with your activity? ......._{YES _____ NO _____}

If YES, explain: ___________________________________________________________

10. Do you have chronic kidney disease (CKD)? …………..……………………_{YES _____ NO _____}

If YES, specify GFR mL/min Don’t know

11. Have you had a dilated eye exam? …………..………………………………._{YES _____ NO _____}

If YES, specify last exam date:..…………………….…………………. MO/YR _____________

12. Do you have retinopathy? ……………………….……………………………. _{YES _____ NO _____}

13. Do you have type 1 diabetes treated with insulin?....................................._{. YES _____ NO _____}

If YES, any change in insulin regimen in the past 6 months? ……….. _{YES _____ NO _____}

14. Do you have type 2 diabetes treated with insulin? …...…………………......_{YES _____ NO _____}

If YES, any change in insulin regimen in the past 3 months…….........._{YES _____ NO _____}

15. Do you have type 2 diabetes treated with non-insulin medication? …........._{YES _____ NO _____}

_{If YES}, any change in medication in the past 30 days? …………........ _{YES _____ NO _____}

Complete APPENDIX A at the end of this document.

_{EXAMINER COMMENTS – Endocrine:}

_{Examiner MUST enter a comment on all positive history / “yes” answers and ensure Appenix A is complete.}

SECTION X. SLEEP DISORDERS Candidate Initials ______

Have you ever had or experienced any of the following:

_{49. Narcolepsy? ……………………}…………………………………………………………………………49_{. YES _____ NO _____}

_{If YES,} is it with cataplexy? …………..…………………………………………………… _{YES _____ NO _____}

50. Obstructive sleep apnea? ……………………………………………………………………………….50_{. YES _____ NO _____}

If YES, answer questions below:

1. Did you have a sleep study? …………..…………………………………. _{YES _____ NO _____}

If YES, What symptoms were you having that prompted the sleep study? (circle all that apply)

Daytime sleepiness Snoring Insomnia

Nocturnal awakenings/not breathing Other ________________________

2. Were you prescribed treatment with CPAP? ……….……………………. _{YES ______ NO _______}

If YES, How many days/wk do you wear your CPAP? How many hrs/night? ________

(If you have a recent CPAP compliance report, please provide to examiner)

51. Shift work disorder? ………………………………………………………………………………………51_{. YES _____ NO _____}

52. If YES to narcolepsy, sleep apnea, or shift work disorder, what are your current symptoms from these conditions?

_{____________________________________________________________________________________________________}

_{EXAMINER COMMENTS – SLEEP DISORDERS:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION XI. PSYCHOLOGICAL

Have you ever had or experienced any of the following:

53. Anxiety disorder? …………………………………………………………………………………………53_{. YES _____ NO _____}

If YES, date of last occurrence of symptoms? ………………………………………... MO/YR ________

54. Panic attack? ……………………………………………………………………………………………..54_{. YES _____ NO _____}

If YES, date of last panic attack? ……………..………………………………………… MO/ YR ________

55. Social anxiety disorder? …………………………………………………………………………………55_{. YES _____ NO _____}

If YES, date of last occurrence of symptoms? ………………………………………… MO/ YR ________

56. Attention deficit/hyperactivity disorder (ADHD)? ..…………………………………………………….56_{. YES _____ NO _____}

If YES, date of last occurrence of symptoms? ………………………………………… MO/ YR ________

57. Bipolar disorder? ………………………………………………………………………………………….57_{. YES _____ NO _____}

If YES, did you ever have a manic episode?.............................................................. _{YES NO ______}

58. Depressive disorder? ……………………………………………………………………………….……58_{. YES _____ NO _____}

If YES, date of last occurrence of symptoms? ……..………………………………….. MO/ YR ________

59. Personality disorder? ………………………………………………………………………………….….59_{. YES _____ NO _____}

60. Post-traumatic stress disorder (PTSD)? .……………………………………………………………….60_{. YES _____ NO _____}

If YES, date of last occurrence of symptoms? …………..…………………………….. MO/ YR ________

61. Psychosis or psychotic features? ………………………………………………………………………. 61_{. YES _____ NO _____}

SECTION XI. (continued) Candidate Initials ______

62. Substance use disorder? …………………………………………………………………………………62_{. YES _____ NO _____}

If YES, answer the questions below:

1. What substance(s)? ____________________________________________________________

2. Date of last use? …………………………………………………………... MO/YR _____________

3. Have you completed a substance use disorder treatment program?..…. _{YES _____ NO _____}

63. Are you being treated for a mental health condition? ………………………………………………..63. _{YES NO _____}

If YES, answer the questions below:

1. Are you treated by a psychologist or psychiatrist? ……………………… MO/YR _________

2. Are you compliant with your treatment

(medications, follow-up appointments, referrals)? ……………………….. _{YES _____ NO _____}

3. Do you have any sedating side effects from your treatment? .………….. _{YES _____ NO _____}

4. Do you have irritability? ….………………………………….………………. _{YES _____ NO _____}

5. Do you have difficulty concentrating? …………….….……………………. _{YES _____ NO _____}

6. Do you have any diagnosed phobias? …….………………………………. _{YES _____ NO _____}

7. _{Has your condition ever interfered with your job or daily activities?......... YES _____ NO _____}

_{If YES, when was the last time your condition interfered with your job or activities?} MO/YR

Please explain: _______________________________________________________________

64. Suicide attempt? ………………………………………………………………………………………….64. _{YES _____ NO _____}

If YES, date: ………………………………………………………………………………….. MO/YR _________

_{65. Electroconvulsive therapy} (ECT)? ………………………………………………………………………65. _{YES _____ NO _____}

If YES, date of last ECT therapy: .………………………………………………………….. MO/YR _________

66. Schizophrenia, schizoaffective, or schizophreniform disorder? ……………………………………...66. _{YES _____ NO _____}

67. Other mental health disorder not previously noted? ………………………………….……………….67_{. YES _____ NO _____}

If YES, specify: ______________________________________________________________________

_{EXAMINER COMMENTS – PSYCHOLOGICAL:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

SECTION XII. ACTIVITY

68. Answer the questions below regarding your ability. Are you able to:

Frequently lift and carry passenger baggage weighing up to 50 pounds without assistance?...ABLE _{UNABLE _______}

Frequently squat, bend and stoop?............................................................................................ABLE _{UNABLE _______}

Frequently reach overhead with each arm? ..……………………………………………………….ABLE _{UNABLE _______}

Stand continuously for up to 4 hours without a break? …………………………………………….ABLE _{UNABLE _______}

Walk for up to 3 miles during a shift? ………………………………………………………………...ABLE _{UNABLE _______}

Feel and manipulate small objects with both hands? ……..………………………………………..ABLE _{UNABLE _______}

Open/close zippers, snaps, and buckles on baggage, backpacks, or briefcases? ……………..ABLE _{UNABLE _______}

SECTION XII. (continued)

_{What is your present activity level?}

_{Circle the level of activity listed below that best describes how often you participate in each of the activities:}

Activit y	Never/R arel y 0 to 2 times per year	Occasi onall y 1 to 2 times per month	Frequentl y Once per week or more
Walk 2 miles continuously	Never/Rarely	Occasionall y	Frequentl y
Run 2 miles continuously	Never/Rarely	Occasionall y	Frequentl y
W eight training /general fitness activity at gym	Never/Rarely	Occasionall y	Frequentl y
Team sports (basketball, football, soccer, etc.)	Never/Rarely	Occasionall y	Frequentl y
Gardening / yard work	Never/Rarely	Occasionall y	Frequentl y
Golf	Never/Rarely	Occasionall y	Frequentl y
W inter sports (skiing, ice skating, etc.)	Never/Rarely	Occasionall y	Frequentl y
Swimming / cycling	Never/Rarely	Occasionall y	Frequentl y
Other (list):	Never/Rarely	Occasionall y	Frequentl y

69. Do you have any restrictions or limitations on your activity or function? ………………………69. _{YES NO _______}

If YES, explain in detail: _____________________________________________________________

70. Do you have anything additional to report that has not already been addressed? ……………70. _{YES NO _______}

If YES, explain: ____________________________________________________________________

_{EXAMINER COMMENTS – ADDITIONAL COMMENTS:}

_{Examiner MUST enter a comment on all positive history / “yes” answers.}

CANDIDATE SIGNS BELOW after reading the following statements:

I certify that I have reviewed the foregoing information supplied by me and it is true and complete to the best of my knowledge. I have read the privacy statement at the beginning of this questionnaire and understand that falsification, misrepresentation or omission of information on Government forms is punishable by fine and/or imprisonment and/or may be grounds for disqualification from TSA employment, or disciplinary or adverse action if employed.

The exam information collected from your appointment for your TSO pre-placement physical will be forwarded to TSA’s primary medical contractor, Comprehensive Health Services (CHS). CHS is the sole authority for rendering TSO medical qualification determinations and they will contact you directly if they have any questions or need any further information to make an eligibility determination.

REQUIRED Candidate Printed Name

Date (mm/dd/yyyy)

REQUIRED Candidate Signature _____________________________________________________________________

FACILITY PROVIDER/EXAMINER (MD, DO, PA, or NP) SIGNS BELOW:

REQUIRED Examiner Printed Name

Date (mm/dd/yyyy)

REQUIRED Examiner Signature

MD, DO, PA, NP (Circle one)

APPENDIX A Candidate Name: _____________________________________________________

If you have a history of Diabetes or Hypertension, complete the following for the purpose of calculating your ASCVD (atherosclerotic cardiovascular disease) risk score according to the American Heart Association and American College of Cardiology. This published formula requires the following information to calculate your ASCVD risk score per the TSO Medical Guidelines: current age, sex, race, systolic blood pressure, total cholesterol, HDL cholesterol, history of diabetes, smoking, and treatment for hypertension. If you know the following information, please circle the correct response and enter the values below:

Race (circle one): White African American Other

Total Cholesterol (mg/dL): _______________ Approximate MO/YR __________ Don’t know ___________

HDL Cholesterol (mg/dL): _______________ Approximate MO/YR __________ Don’t know ___________

Smoker (circle one): Yes Former No

PUBLIC BURDEN STATEMENT: TSA is collecting this information to determine your suitability to serve as a TSO. This is a voluntary collection of information; however, failure to furnish the requested information may result in an inability to consider your eligibility for employment as a TSO. TSA estimates that the total average burden per response associated with this collection is approximately 1.65 hours, including the time for reviewing instructions, getting needed information, travel time to receive the necessary medical screening and reviewing the completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing burden, to the U.S. Office of Personnel Management (OPM), Strategic Human Resources Policy, Medical Policy and Programs Division, Attn: OMB Number (1652-0032), 1900 E Street, NW, Washington, D.C. 20415. The control number assigned to this collection is OMB 1652-0032, which will expire on 7/31/2019. 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.

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; failure to furnish the requested information may result in an inability to consider your application for employment.

Previous editions of this form are obsolete.

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