Information Collection

Mental Health Certification

IC 46519 under ICR 202605-1652-001 · OMB 1652-0043.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form TSA Form 1164 Mental Health Certification Mental Health Certification	Form and Instruction
TSA Form 1164 Mental Health Certification TSA Form 1164, Mental Health Certification (10-2023) FINAL.pdf	Form and Instruction

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	TSA Form 1164				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: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.

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