Form TSA Form 417 TSA Form 417 Screening Assistance Request

OMB control number 1652-0069
Exp.04/30/2025
DEPARTMENT OF HOMELAND SECURITY
Transportation Security Administration

SCREENING ASSISTANCE REQUEST

INSTRUCTIONS: This form is to be completed in accordance with OD-400-45-4 series, Establishment and Functions of the Transportation
Security Administration Wounded Warrior/ Military Severely Injured Joint Support Operations (MSIJSOC) for service members who are
verified and registered with an official U.S. military service/ component of the Wounded Warrior Program and their traveling companion(s)
who are eligible to receive expedited screening. The MSIJSOC will email the completed form to the respective FSD- designated employee
at the appropriate airport to assist the Wounded Warrior and traveling companions. For additional questions, please contact
[email protected].
Section I. Military Severely Injured Center Contact Information
From:
Military Severely Injured (MSI) Center TSA Liaison Team
Phone:

703.603.1558; 1-888-262-2396 (Toll Free)

Email:

[email protected]

Date:

(Preferred method)

Time:

TSA Liaison:

Section II. Passenger Information

Veteran/Family Member Traveling

Name:

Branch:

Email:

Rank:

Caregiver:
POC:

Mobile Phone:
Mobile Phone:

Depart Airport

Airline

Flight #

Traveling Party Members
Other Than Service Member

Flight Itinerary
Depart Time

Arrival Time

Number of Adults

Arrival Airport

Date of Travel

Number of Children

NOTES: SPECIAL NEEDS FOR TRAVELING

Privacy Act Statement: AUTHORITY: 49 U.S.C. § 44927. PRINCIPAL PURPOSE(S): This information is used to coordinate and provide
airport security screening assistance to eligible travelers. ROUTINE USE(S): This information may be shared in accordance with the
Privacy Act of 1974, 5 U.S.C. §552(a), or for routine uses identified in the TSA system of records, DHS/TSA-001, Transportation Security
Enforcement Record System. DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the requested
information may prevent TSA from providing assistance through airport security screenings to eligible travelers. Paperwork Reduction
Act Statement: The collection involves the submission of travel information to Transportation Security Administration to provide wounded
warrior, severely injured military personnel, and certain other travelers with assistance through the airport security screening process. This
is a voluntary collection. It is estimated that the total average burden per response associated with this collection is approximately 5
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 valid OMB control number. The control number assigned to this collection is OMB 1652-0069 which expires 04/30/2025. 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 22150. ATTN: PRA 1652- 0069.

Previous editions of this Form are obsolete.
TSA Form 417 (12/24) rev. [File: 400.7.1]

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