Form TSA Form 1163 TSA Form 1163 Treating Physician Status Report

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

TREATING PHYSICIAN STATUS REPORT

OMB Control Number: 1652-0043 Expiration Date: 07/31/2019

INSTRUCTIONS: Your patient is undergoing evaluation by the Federal Air Marshal Service Medical Program pursuant to either an application for employment or determination of fitness for duty. We request that you complete this form to assist us in our evaluation. Unless directed by the FAMS Medical Programs Section, this form may be completed by an Advanced Practice Registered Nurse (APRN). Please provide the following information according to patient records. Please include comments about any side effects the patient has experienced. Include all current medications. The Federal Air Marshal Service will not be financially responsible for additional testing. 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. Patient Information
Name:	Date of Birth:
Section II. Medical History
Diagnosis (Please list below):
Medical History (Please list below):
Treatment and Medical Dosage (Please list below):
Prognosis (Please list below):
Section III. Healthcare Provider's Information
Healthcare Provider's Signature:		Date:
Healthcare Provider's Printed Name:		Telephone Number:
Healthcare Provider's Office Street Address:
City, State, Zip Code:		Fax Number:

PRIVACY ACT STATEMENT: Authority: 49 U.S.C. § 114(n), 14 C.F.R. Part 67. Principal Purpose(s): This information will be used to determine your suitability to serve as a Federal Air Marshal. Routine Use(s): This information may be shared in response to a request for discovery or for an appearance of a witness, when it is relevant to the subject matter involved in a pending judicial or administrative proceeding, 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 you for a position as a Federal Air Marshal.

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: TSA is collecting this information about you to determine your suitability to serve as a Federal Air Marshal. This is a voluntary collection of information; however, failure to furnish the requested information may result in an inability to consider you for a position as a Federal Air Marshal. TSA estimates that the total average burden per response associated with this collection is approximately one hour (or 15 minutes if not submitting an explanation). 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. The control number assigned to this collection is OMB 1652-0043, which expires 07/31/2019. Send comments regarding this burden estimate or collection to: TSA-11, Attention: PRA 1652-0043, Law Enforcement/Federal Air Marshal Service Physical Mental Health Certification, 601 South 12th Street, Arlington, VA 20598-6011.

TSA Form 1163 (11/18) [File: 1100.2.3-a]

Previous editions of this form are obsolete.

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