Mental Health Certification

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0043 can be found here:

Documents and Forms

Document Name Document Type
Form TSA Form 1164 Mental Health Certification Form and Instruction
TSA Form 1164 Mental Health Certification TSA Form 1164, Mental Health Certification 6.26.2019.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Mental Health Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 14 CFR 67

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 1164	Mental Health Certification	TSA Form 1164, Mental Health Certification 6.26.2019.docx		Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: Employee Medical File System Records	FR Citation: 65 FR 24750

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	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.