Form TSA Form 3417 TSA Form 3417 CMSDT Program Attendance Roster

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

CMSDT PROGRAM ATTENDANCE ROSTER

OMB Control No.1652-0028 Expires: 04/30/2022

INSTRUCTIONS: The Crew Member Self Defense (CMSD) Trainer shall complete Section I. with the field office location and date of training. Section II. shall be completed by the trainer or the trainee with the trainee name, airline affiliation, airline ID number and contact information. The CMSD Trainer will verify if the training has been completed, if a certification was received and sign and date Section III.
SECTION I. Training Information
Field Office Location				Date of Training
SECTION II. Roster Information
TO BE COMPLETED BY TRAINER OR TRAINEE					TO BE COMPLETED BY TRAINER
Name	Airline Affiliation	Airline ID Number	Contact Information (Mailing Address/Email/Phone Number)		Training Complete	Certification Received
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
						Yes	No
SECTION III. Signatures
Instructor Signature				Date

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f). PRINCIPAL PURPOSE(S): The information will be used to verify attendance at the Crew Member Self Defense Training Program, whether or not the training was completed and if a certification was received. ROUTINE USE(S): This information may be shared with educational institutions or training facilities for purposes of enrollment and verification of attendance and performance, or for routine uses identified in the Department of Homeland Security's system of records notice, DHS/ALL-003 Department of Homeland Security General Training Records. DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to verify your attendance at the Crew Member Self Defense Training Program, whether or not the training was completed and if a certification was received.

PAPERWORK REDUCTION ACT STATEMENT: Through this voluntary collection of information, TSA is gathering information about you to confirm your attendance at TSA's crew member self-defense training course. The public burden for this collection of information is estimated to be five minutes. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0028, which expires 04/30/2022. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to TSA PRA Officer, 6595 Springfield Center Drive, Springfield, VA 20598-6011. ATTN: PRA 1652-0028.

Previous editions of this form are obsolete.

TSA Form 3417 (4/20) rev. [File: 3500.13] Page 1 of 1