Information Collection

TSO Medical Questionnaire and Evaluation; Travel

IC 191700 under ICR 201904-1652-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.