Law Enforcement/Federal Air Marshal Service (OLE/FAMS) Physical and Mental Health Certification

Forms and Documents

Document Name	Status
Form TSA Form 1164 Mental Health Certification Form and Instruction	Modified
Form TSA Form 1163 Treating Physician Status Report Form and Instruction	New
Form TSA Form 1133-3 Practical Exercise Performance Requirements (PEPR) form Form and Instruction	New
privacy-pia-dhs-all043-hiring and onboarding-april2017.pdf Supplementary Document	2019-06-04
opm-sorn-govt-5-recruiting-examining-and-placement-records.pdf Supplementary Document	2019-06-04
1652-0043 LEFAMS PMHC 30DN 84 FR 23062 (5.21.2019).pdf Supplementary Document	2019-06-03
1652-0043 LEFAMS PMHC 60DN 83 FR 62878 (12.6.2018).pdf Supplementary Document	2019-06-03
1652-0043 LEFAMS PMHC SS 6.3.2019.docx Supporting Statement A	2019-06-04
DHS-TSA 001.pdf Supplementary Document	2010-09-24
OPM-GOVT-10%20-%20Medical%20Records[1].pdf Supplementary Document	2010-09-24
49 USC 44917[1].doc Supplementary Document	2007-08-29
49 USC 44903[1].doc Supplementary Document	2007-08-29
49 USC 44901[1].doc Supplementary Document	2007-08-29

IC Document Collections

IC ID	Document Title	Status
46519	Mental Health Certification Form and Instruction	Modified
236329	Treating Physician Status Report Form and Instruction	New
236328	Practical Exercise Performance Requirements (PEPR) form Form and Instruction	New

ICR Details

OMB Control No: 1652-0043	ICR Reference No: 201906-1652-001
Status: Active	Previous ICR Reference No: 201601-1652-004
Agency/Subagency: DHS/TSA	Agency Tracking No:
Title: Law Enforcement/Federal Air Marshal Service (OLE/FAMS) Physical and Mental Health Certification
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/14/2020
	Date Received in OIRA: 07/31/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2023	36 Months From Approved	07/31/2020
Responses	1,800	0	600
Time Burden (Hours)	900	0	600
Cost Burden (Dollars)	0	0	0

---

Abstract: In furtherance of TSA's authority to provide for deployment of Federal Air Marshals (FAMs) on passenger flights, and provide for appropriate training, supervision, and equipment of FAMs TSA policy requires that applicants for Law Enforcement/ Federal Air Marshal positions meet certain medical standards. The medical guidelines ensure a level of health status and physical and psychological fitness for this public safety law enforcement position which requires a high degree of responsibility. Medical guidelines are based on cognitive, physical, psychomotor, and psychological abilities related to the essential job functions of a FAM

---

Authorizing Statute(s): US Code: 49 USC 44903 Name of Law: ATSA
   US Code: 49 USC 44917 Name of Law: ATSA
   US Code: 49 USC 44901 Name of Law: ATSA
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 62878	12/06/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 23602	05/21/2019
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Mental Health Certification	TSA Form 1164	Mental Health Certification
Practical Exercise Performance Requirements (PEPR) form	TSA Form 1133-3	Practical Exercise Performance Requirements
Treating Physician Status Report	TSA Form 1163	Treating Physician Status Report

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1,800	600	0	0	1,200	0
Annual Time Burden (Hours)	900	600	0	0	300	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Although there are no changes to the information being collected, as noted in the response to Item 2, the collection is being revised to include the following additional forms: (1) TSA Form 1163, Treating Physician Status Report (TPSR), and (2) TSA Form 1133-1, Practical Exercise Performance Requirements (PEPR), to assist in the determination and in conjunction with further evaluation requests as needed for applicants of a FAMs position or incumbent FAMs. Additionally, TSA is revising the name of the collection from “Office of Law Enforcement/Federal Air Marshal Service Mental Health Certification” to “Law Enforcement/Federal Air Marshal Service Physical and Mental Health Certification.” Finally, TSA is also revising the collection process to allow other authorized healthcare providers to certify the applicant’s or incumbent FAM’s medical status, when applicable. TSA has modified the PEPR form and the TPSR form to accept paperwork signed by an APRN in non-complex cases. TSA expects the modification of the forms will ease the burden of compliance by expanding the field of individuals, physician or APRN, who can be consulted to comply with the regulatory requirements. TSA will submit this collection as a Deregulatory Action. In Item 13, the change noted includes the removal of costs associated with mailing the documents. TSA revised the estimated cost to the Federal Government reported in Item 14 based on an update to the TSA wage rate and the number of respondents.

---

Annual Cost to Federal Government: $3,175

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/31/2019

---