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TSA uses this form to obtain information relevant to an applicant’s health status for purposes of making an employment decision. This is a mandatory collection of information if you wish to be considered for a TSA Security Officer position. It is estimated that the total average burden per response associated with this form is approximately 40 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.\u003Cbr>PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S. C. 44935 PRINCIPAL PURPOSE(S): This information will be used to determine your eligibility for employment as a Transportation Security Officer (TSO) . ROUTINE USE(S): This information may be shared with contractors, grantees, or volunteers performing or working on a contract, service, grant, cooperative agreement, or job for the federal government, or for routine uses identified in the Office of Personnel Management’s system of records notice, OPM/GOVT-10 Employee Medical File System Records (if hired) or OPM/GOVT-5 Recruiting, Examining, and Placement Records (if not hired) . DISCLOSURE: Voluntary; failure to furnish the requested information may result in an inability to consider your application for employment. |  |  |\n| INSTRUCTIONS |  |  |\n| It is required that you complete each question or response in this questionnaire. After completing each page record your initials in the space provided at the bottom of each page. Your responses will be reviewed with you by a medical professional. |  |  |\n| DEMOGRAPHIC INFORMATION |  |  |\n| Name (Print):  \u003Cbr>Address:  \u003Cbr>______________________________________\u003Cbr>Home Phone \\#: (  )   -  Work Phone \\#: (  )   -  Other Phone \\#: (  )   -  Best Time to Call:\u003Cbr>______________________________________ | Social Security \\# (last 4 digits):   Sex: Male   Female  \u003Cbr>Date of Birth:  / / \u003Cbr>(mm / dd / yyyy)\u003Cbr>Height:   Feet   Inches\u003Cbr>Weight:   lbs |  |\n| GENERAL INFORMATION |  |  |\n| 1. Have you been refused employment,dismissed from a job,or unable to 1. Yes  No  stay in school due to any medical condition or excessive absenteeism?\u003Cbr>If yes, please list each medical condition and record the year of the refusal:\u003Cbr>2. Have you ever been diagnosed or treated for a mental health condition? 2. Yes  No  If yes , specify the year for each mental health condition and provide details: |  |  |\n| 3. Have you had, or have you been advised to have, any operations? If yes , describe what type of operation and indicate date if appropriate |  | 3. Yes  No  |\n|  |  |  |\n| 4. Have you been treated at any type of hospital in the last 10 years? If yes , specify when and reason for treatment |  | 4. Yes  No  |\n| 5. Have you ever had any illness, injury, or condition (including learning 5. Yes  No  Don't Know  \u003Cbr>disability, attention deficit disorder, etc. ) other than those already noted above?\u003Cbr>If yes , specify medical condition and when you were treated |  |  |\n\nTSA Form 1130A-1, 12/09 [File: 1100.0. 1]  \nOMB control number 1652-0032; Expiration Date: [mm/dd/yyyy] Page 1 of 6 Candidate Initials    \n\n| \u003Cbr>GENERAL INFORMATION (continued) |  |  |\n| --- | --- | --- |\n| 6. Have you consulted or been treated by clinics, physicians, healers, or 6. Yes  No \u003Cbr>other practitioners within the past year for anything other than minor illnesses?\u003Cbr>If yes , provide an explanation and the name of doctor consulted and/or the hospital/clinic\u003Cbr>7. Have you ever been rejected for military service or law enforcement 7. Yes  No  position(s) because of physical, mental, or other medical reasons?\u003Cbr>If yes , give date and reason for rejection:\u003Cbr>\u003Cbr>\u003Cbr>8. Have you ever bee","cbCaieO1mrGETYP2","https://ap.wps.com/l/cbCaieO1mrGETYP2","pdf",59150,"English","# Transportation Security Officer Medical Questionnaire\n## Paperwork Reduction Act & Privacy Act Statement\n## Instructions\n## Demographic Information\n## General Information","[{\"question\":\"What is the purpose of this TSA medical questionnaire?\",\"answer\":\"TSA uses the form to collect information related to an applicant’s health status for an employment decision for a Transportation Security Officer position.\"},{\"question\":\"What information does the form ask for in demographic sections?\",\"answer\":\"It requests name, address, home/work/other phone numbers and best time to call, plus Social Security number (last 4 digits), sex, date of birth, height, and weight.\"},{\"question\":\"What are the key instructions for completing the questionnaire?\",\"answer\":\"You must answer each question or response, and after completing each page record your initials in the space provided. Your responses are reviewed with you by a medical professional.\"}]","Transportation Security Officer Medical Questionnaire - Paperwork Reduction Act & Privacy Act Statement - Instructions - Demographic Information - General Information | PDF",15]