TSA Form 1130B-13 Orthopedic Further Evaluation

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Orthopedic Further Evaluation

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: _______________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

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.

CANDIDATE SECTION:

• Candidate must complete Candidate section, including signature

• 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

1. Have you ever missed work/school due to your orthopedic injury/surgery? □ Yes □ No

2. Do you currently have any pain associated with your orthopedic condition? □ Yes □ No

3. Do you take medication for the pain? □ Yes □ No

4. If yes, what medication and how often do you take it? __________________________________

5. Do you have difficulty with any of the following and if so explain: ___________________________________________

□ Standing for up to 3 hours □ Sitting for up to 3 hours □ Stooping / bending

□ Lifting heavy objects on regular basis (_____ lbs)

Candidate Signature: _______________________________________ Date: ____________________________

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

HEALTH CARE PROVIDER SECTION:

• Health Care Provider must verify candidate’s identification with a government issued photo ID, e.g., driver’s license or passport

• Health Care Provider must complete Health Care Provider section, including signature, printed name, contact number

• Health Care Provider must review, sign and date the attached “Transportation Security Officer Job Requirements Overview” and determine candidate’s ability to perform this job in relation to the above indicated condition

1. Diagnosis: ______________________________________________ Date of diagnosis: ______________________

2. Prognosis ____________________________________________________________________________________

3. What medication(s) is the candidate currently taking for this condition?

Medication: Dose: Frequency: :

______________________________________________________________________________________________

______________________________________________________________________________________________

4. Date of Surgery (If applicable): _________________________________________________________ (mm/dd/yyyy)

5. List any physical restrictions: ______________________________________________________________________

6. Any additional information: ______________________________________________________________________

It is very important to send supporting documentation – 12 months of progress notes, diagnostic test results, treatment summary and CURRENT orthopedic evaluation to CHS for Medical Director’s review. Please complete the attached orthopedic assessment and “Transportation Security Officer (Screener) Job Requirements Overview” pages.

Physician Signature: _____________________________________ Date: _________________________________

Please Print Physician Name: _____________________________ Medical Specialty: ______________________

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

FAX ALL SUPPORTING DOCUMENTATION, PROGRESS NOTES, AND RECENT DIAGNOSTIC TEST RESULTS INCLUDING

ALL PAGES OF THIS FORM TO CHS. If unable to fax please call 866-416-5928.

Fax 703-288-5495

C Orthopedic Further Evaluation andidate Name: Last 4 Digits of SSN: __ __ __ __
ORTHOPEDIC ASSESSMENT
Please perform the orthopedic screening in relation to the candidate’s ability to handle, search and repeatedly lift baggage weighing up to 70 lbs on a daily basis, and continuously stand or ambulate for up to 3 hours. Record “NORMAL” if the test is completed successfully. Record “ABNORMAL” if unsuccessful. Provide description of the limitations as seen during this screening process.
		Observations / Comments Required if abnormal
1. Gait	Have the candidate ambulate towards you in a normal manner Have candidate repeat on his/her toes Have candidate repeat on his/her heels
2. Hip, Knee, Ankle	Ask candidate to stand with feet shoulder width apart facing examiner. Ask candidate to squat down and return to the starting position. Repeat as needed to fully assess.
3. T + L Spine (Thoracolumbar flexion & extension	Ask candidate to bend at waist with knees extended and attempt to touch the floor or his/her toes Repeat as needed to fully assess ability.
4. Balance, Shoulder (Left – Hyperabduction, supination, pronation)	Ask candidate to stand on left leg and bring his/her arms from his/her side over his/her head and touch the palmar surfaces of his/her hands together and then return arms to the original starting position Repeat as needed to fully assess
5. Balance, Shoulder (Right Hyperabduction, supination, pronation)	Ask candidate to stand on right leg and bring his/her arms from his/her side over his/her head and touch the palmar surfaces of his/her hands together and then return arms to the original starting position Repeat as needed to fully assess
6. Elbow Flexion & Extension	Ask candidate to fully flex and extend elbows Repeat as needed to fully assess
7. Hand (A/ROM all joints and amputation check)	Ask candidate to flex elbows 90 degrees with hands in a pronated starting position and open and close hands Determine the A/ROM of the applicable joints Assess whether the candidate has any amputations
8. Wrist (A/ROM all joints and amputation check)	Ask candidate to flex elbows 90 degrees with hands in a pronated starting position Ask candidate to perform A/ROM of his/her wrists in all available planes (i.e. flex, ex RD, UD) Repeat as needed to fully assess
9. Opposition	Ask candidate to touch the tip of his/her thumb to each fingertip Repeat as needed to fully assess
10. C-Spine (A/ROM All Planes)	Ask candidate to perform A/ROM of c-spine in all available planes in standing position (i.e. flex, extend LSB, RSB, L Rotate, R Rotate) Repeat as needed to fully assess

Orthopedic Further Evaluation

Candidate 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 Pages 1and 2.

• 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 Pages 1and 2.

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-13, 12/09 [File: 1100.0.1] OMB control number 1652 - 0032; Expiration Date: 03/31/2016