Transportation Security Officer Medical Clearance

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OMB 1652-0032
Exp. 12/31/2026
DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
TRANSPORTATION SECURITY OFFICER MEDICAL CLEARANCE

INSTRUCTIONS: This form must be completed by a licensed physician or other licensed healthcare practitioner in
connection with a physical examination of a Candidate for a Transportation Security Officer position with the Transportation
Security Administration (TSA). Return the completed form to the Candidate for submission to TSA. The Candidate was
informed that they are responsible for any costs of the physical examination.
SECTION I.
Name of Applicant:
Date:
The above-named individual is tentatively selected for a Transportation Security Officer (TSO) position with the
Transportation Security Administration. The duties of a TSO include the following:

• Carry up to 50 pounds without assistance
• Stand for up to 4 hours
• Feel and manipulate small objects with both hands
• Communicate effectively with the public and coworkers
• Make decisions effectively in both crisis and routine situations
• Maintain focus and awareness during an entire shift
• Identify and locate prohibited items while working in an environment containing numerous distractions
• Perform shift work and night work
You can find a complete list of the medical requirements and essential job functions at
https://www.tsa.gov/sites/default/files/hc-job-tso-medical-guidelines.pdf
“Provide restrictions” is standard occupational medicine terminology and is used throughout the medical guidelines. It
means that an employee or an applicant is not medically cleared for full and unrestricted duties of their occupation.
In your medical opinion, is the above-named individual able to perform these functions?
Yes (cleared)

No (not cleared)

Name of Licensed Health Practitioner:
MD/DO

NP/APRN

PA

Other Practitioner (specify):

Signature of Licensed Physician or Licensed Health Practitioner

Office Phone

(Continued on next page)

WARNING: This document may contain Privacy Act protected or other sensitive information and should be protected from
unauthorized disclosure. TSA employees and contractors may share this information within DHS on a need-to-know
basis. Disclosure outside of DHS must be approved by the Chief Counsel’s Office or TSA Privacy Office.

TSA Form 1137-1 (9/26) rev. [File: 1100.2.2]

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SECTION II. MEDICAL EXAMINATION
Name of Applicant:
Vital Signs
Pulse:

Blood Pressure:

Respiratory Rate:

Visual Acuity
Corrected distant visual acuity: OD 20/

OS 20/

OU 20/

TSA requires a corrected distant visual acuity of 20/20 OU.
Peripheral Vision
Test by confrontation: at least 120° field of vision in horizontal meridian measured using both eyes.
Normal
Abnormal (provide test results):

Color Vision: follow pass/fail criteria specified by the test used
Normal
Abnormal (provide test results):

Hearing
Whisper Test (must be performed over 5 feet away):

Pass

Fail

WARNING: This document may contain Privacy Act protected or other sensitive information and should be protected
from unauthorized disclosure. TSA employees and contractors may share this information within DHS on a needto-know basis. Disclosure outside of DHS must be approved by the Chief Counsel’s Office or TSA Privacy Office.
PUBLIC BURDEN STATEMENT: TSA is collecting this information to determine suitability to serve as a Transportation Security
Officer (TSO). This is a voluntary collection of information; however, failure to furnish the requested information may result in an
inability to consider your eligibility for employment as a TSO. TSA estimates that the total average burden per response
associated with this collection is approximately 0.50 hours, including the time for reviewing instructions and getting needed
information. 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 OMB number control number assigned to this collection of information is
1652-0032, which expires on 12/31/2026. Send comments regarding our estimate or any other aspect of this form, including
suggestions for reducing burden, to DHS/TSA, [email protected] or TSA-11, Transportation Security Administration, 6595
Springfield Center Drive, Springfield, Virginia 20598-6011. Attn: PRA 1652-0032 Transportation Security Officer Medical
Questionnaire.

TSA Form 1137-1 (9/26) rev. [File: 1100.2.2]

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