TSA Form 1130B-11 Pacemaker Further Evaluation

C

Implanted Pacemaker

Explanation of Risk(s) Verification

andidate Name: Last 4 Digits of SSN: __ __ __ __

MEDICAL CONDITION:

This candidate is under consideration for a position as a Transportation Security Officer (TSO) position at the Transportation Security Administration (TSA). His/her pre-employment medical screening, including a medical history review on _________________________________, revealed the following:

Implanted Pacemaker

Paperwork Reduction Act Statement

The Transportation Security Administration (TSA) requires physical/medical examinations prior to an individual’s appointment to a TSA Security Officer position. 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 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 for this collection is OMB control number 1652-0032, which expires 3/31/2016.

PHYSICIAN INSTRUCTIONS:

This candidate has applied for a Transportation Security Officer (TSO) position with the Transportation Security Administration (TSA). During medical screening this candidate revealed having an implanted pacemaker.

Transportation Security Officers (Screeners) routinely use or come into contact with electromagnetic equipment including but not limited to walkthrough magnetometers and handheld magnetometers. These devices are used by multiple persons in a small, often confined working area.

Please discuss the potential risks that a candidate may encounter by working with or around machinery with electromagnetic fields. The potential risks are typically delineated in the manufacturers’ literature accompanying the pacemaker.

CANDIDATE ACKNOWLEDGEMENT:

Please acknowledge that you have received information regarding the risks of working around or with equipment with electromagnetic fields and understand the potential risks by signing the acknowledgment below­. You must sign this form in the presence of your physician. You also understand that if you are employed or hired as a TSO that you will be required to work with and around electromagnetic equipment.

________________________________ _________________________________ _______________________ __________

Candidate’s Signature Candidate’s Printed Name Candidate’s SSN Date

• Any expenses incurred remain your responsibility and will not be reimbursed by CHS or TSA

PHYSICIAN ACKNOWLEDGEMENT:

Your signature acknowledges that you have explained any potential risks to the candidate and that you have witnessed the candidate signing acknowledgement of the potential risks.

________________________________ _________________________________ _______________________ __________

Physician’s Signature Physician’s Name Printed Physician’s Area of Specialty Date

• Candidate will not receive further consideration in the TSO job application process if CHS does not receive ALL requested paperwork within 90 days of the candidate being placed on Further Evaluation for the position

• Note: physician and candidate acknowledgement must BOTH be completed and signed

Fax this signed form and a copy of the implant manufacturer’s instructions or warning sheets

to CHS. If unable to fax please call 866-416-5928.

Fax 703-288-5495

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Implanted Pacemaker Explanation of Risk(s) Verification

andidate Name: Last 4 Digits of SSN: __ __ __ __

Transportation Security Officer (TSO) Job Overview

from Vacancy Announcement on www.usajobs.gov

1. A TSO must be willing and able to:

• Repeatedly lift and carry up to 70 pounds;

• Continuously stand for anywhere between one (1) to four (4) hours without a break to carry out screening functions;

• Walk up to two (2) miles during a shift;

• Continuously and effectively interact with the public, giving directions and responding to inquiries in a reasonable tone and manner;

• Maintain focus and awareness and work within a stressful environment which includes noise from alarms, machinery, and people, distractions, time pressure, disruptive and angry passengers, and the requirement to identify and locate potentially life threatening devices and devices intended on creating massive destruction; and

• Make effective decisions in both crisis and routine situations.

2. TSO medical standards include but are not limited to:

• Visual ability including two functioning eyes with:

• Distance vision correctable to 20/30 or better in the best eye and 20/100 or better in the worse eye;

• Near vision correctable to 20/40 or better binocular;

• Color perception (e.g., red, green, blue, yellow, orange, purple, brown, black, white, gray). Note: color filters (e.g., contact lenses) for enhancing color discrimination are prohibited;

• Hearing (corrected or uncorrected) as measured by audiometry cannot exceed:

• an average hearing loss of 25 decibels (ANSI) at 500, 1000, 2000 and 3000 Hz in each ear, and

• single reading of 45 decibels at 4000 and 6000 Hz in each ear;

• Adequate joint mobility, dexterity and range of motion, strength, and stability to repeatedly lift and carry up to 70 pounds; and

• Blood pressure not to exceed 140 / 90.

Physician Review

Based on my findings and opinions presented in the Health Care Provider Section of this form, this candidate:

• Is capable of meeting the above job requirements safely, efficiently and effectively with respect to my medical specialty and this candidate’s medical condition and/or diagnosis noted on Page 1.

• Is NOT capable of meeting the above job requirements safely, efficiently and effectively with respect to my medical specialty and this candidate’s medical condition and/or diagnosis noted on Page 1.

Specify reason(s) and provide explanation based on the above reference number(s): ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Physician Signature: ______________________________________ Date: ________________________

Please Print Physician Name: ____________________________ Medical Specialty: ______________________

Phone Number: (__ __ __) __ __ __ - __ __ __ __ FAX Number: (__ __ __) __ __ __ - __ __ __ __

Note: All data provided by the candidate’s physician(s) are part of an initial medical evaluation. The final determination of medical suitability will be made by Transportation Security Administration medical staff based on the aggregate of all medical data acquired.

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.

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TSA Form 1130B-11, 12/09 [File: 1100.0.1] OMB control number 1652 - 0032; Expiration Date: 03/31/2016