TSO Medical Questionnaire and Evaluation; Travel

Transportation Security Officer Medical Questionnaire

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form TSA Form 1130A-1 TSO Medical Questionnaire and Evaluation; Travel Form and Instruction
TSA Form 1130A-1 TSO Medical Questionnaire TSA Form 1130A-1 (6.12.2019).docx Form and Instruction

Information Collection (IC) Details

IC Title:	TSO Medical Questionnaire and Evaluation; Travel	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	TSA Form 1130A-1	TSO Medical Questionnaire	TSA Form 1130A-1 (6.12.2019).docx		No		Paper Only

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: DHS TSA 022	FR Citation: 71 FR 40530

Number of Respondents: 22,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	22,500	-6,517	29,017
Annual IC Time Burden (Hours)	37,125	23,054	14,071
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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