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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TSA Form 1164 Mental Health Certification	Form and Instruction	Modified	Available
Form TSA Form 1164 Mental Health Certification	Form and Instruction	Modified	Repair queued
Form TSA Form 1133-3 Practical Exercise Performance Requirements	Form and Instruction	New	Available
Form TSA Form 1163 Treating Physician Status Report	Form and Instruction	New	Available
Form TSA Form 1163 Applicants' Time Waiting as Healthcare Provider Completes Forms	Form and Instruction	New	Repair queued
Form TSA Form 1133-3 Practical Exercise Performance Requirements	Form and Instruction	New	Available
Form TSA Form 1163 Treating Physician Status Report	Form and Instruction	New	Available
Form TSA Form 1163 Applicants Travel Time	Form and Instruction	New	Repair queued
Form TSA Form 1163 Treating Physician Status Report	Form and Instruction	Modified	Available
Form TSA Form 1163 Treating Physician Status Report	Form and Instruction	Modified	Available
Form TSA Form 1133-3 Practical Exercise Performance Requirements	Form and Instruction	Modified	Available
Form TSA Form 1133-3 Practical Exercise Performance Requirements (PEPR) form	Form and Instruction	Modified	Repair queued
privacy-pia-dhs-all043-hiring and onboarding-april2017.pdf	Supplementary Document	Uploaded 2019-06-04	Repair queued
opm-sorn-govt-5-recruiting-examining-and-placement-records.pdf	Supplementary Document	Uploaded 2019-06-04	Repair queued
1652-0043 LEFAMS PMHC 30DN_88 FR 27525 (5.2.2023).pdf	Supplementary Document	Uploaded 2023-05-02	Repair queued
1652-0043 LEFAMS PMHC 60DN 83 FR 62878 (12.6.2018).pdf	Supplementary Document	Uploaded 2019-06-03	Repair queued
1652-0043 LEFAMS PMHC SS 5.2.2023.docx	Supporting Statement A	Uploaded 2023-05-02	Repair queued
DHS-TSA 001.pdf	Supplementary Document	Uploaded 2010-09-24	Repair queued
OPM-GOVT-10%20-%20Medical%20Records[1].pdf	Supplementary Document	Uploaded 2010-09-24	Repair queued
49 USC 44917[1].doc	Supplementary Document	Uploaded 2007-08-29	Available
49 USC 44903[1].doc	Supplementary Document	Uploaded 2007-08-29	Available
49 USC 44901[1].doc	Supplementary Document	Uploaded 2007-08-29	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46519	Mental Health Certification	Form and Instruction	Modified	Mental Health Certification
46519	Mental Health Certification	Form and Instruction	Modified
259987	Applicants' Time Waiting as Healthcare Provider Completes Forms	Form and Instruction	New	Practical Exercise Performance Requirements
259987	Applicants' Time Waiting as Healthcare Provider Completes Forms	Form and Instruction	New	Treating Physician Status Report
259987	Applicants' Time Waiting as Healthcare Provider Completes Forms	Form and Instruction	New
259986	Applicants Travel Time	Form and Instruction	New	Practical Exercise Performance Requirements
259986	Applicants Travel Time	Form and Instruction	New	Treating Physician Status Report
259986	Applicants Travel Time	Form and Instruction	New
236329	Treating Physician Status Report	Form and Instruction	Modified	Treating Physician Status Report
236329	Treating Physician Status Report	Form and Instruction	Modified
236328	Practical Exercise Performance Requirements (PEPR) form	Form and Instruction	Modified	Practical Exercise Performance Requirements
236328	Practical Exercise Performance Requirements (PEPR) form	Form and Instruction	Modified

ICR Details

OMB Control No: 1652-0043	ICR Reference No: 202305-1652-002
Status: Active	Previous ICR Reference No: 201906-1652-001
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: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/02/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/02/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2026	36 Months From Approved	09/30/2023
Responses	300	0	1,800
Time Burden (Hours)	225	0	900
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:
	88 FR 4842	01/25/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 27525	05/02/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Applicants Travel Time	TSA Form 1163, TSA Form 1133-3	Treating Physician Status Report ,   Practical Exercise Performance Requirements
Applicants' Time Waiting as Healthcare Provider Completes Forms	TSA Form 1163, TSA Form 1133-3	Treating Physician Status Report ,   Practical Exercise Performance Requirements
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

table that charts list 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	300	1,800	0	0	-1,500	0
Annual Time Burden (Hours)	225	900	0	0	-675	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: There are no program changes. However, TSA adjusted the respondents for accuracy. In previous ICRs, TSA included TSA FAMS in the number of respondents. TSA is correcting the burden to show only actual members of the public who complete the forms, such as applicants and medical providers. TSA is also including travel and waiting times within the annual burden..

---

Annual Cost to Federal Government: $1,272

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: 05/02/2023

---