TSA Form 1130B-16 Seizure Further Evaluation

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Seizure 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: History of Seizure(s)

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. What was the date of your last seizure? _________________________________________________ (mm/dd/yyyy)

2. How many seizures have you had in the past year? _________________________________________

3. What type of seizure(s) do you have? ____________________________________________________________

4. After taking your medication do you have any of the following symptoms?

□ Dizziness □ Headaches □ Nausea □ Confusion □ Slurred Speech □ None

5. Have the seizures or the medication taken for seizures ever caused you to miss work/school? □ Yes □ No

6. Have the seizures or medication taken for seizures ever interfered with your activities of daily living? □ Yes □ No

If yes, please describe: _________________________________________________________________________

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. Date of last seizure: __________________________________________________________________ (mm/dd/yyyy)

2. What medication(s) is the candidate currently taking for seizures?

Medication: Dose: Frequency: :

______________________________________________________________________________________________

______________________________________________________________________________________________

3. What type / class of seizure is the candidate diagnosed with? _____________________________________________

4. Does the candidate have any other medical conditions related to his/her seizure disorder? ______________________

_______________________________________________________________________________________________

5. What did the last 3 lab results indicate as far as medication compliance? ____________________________________
   _______________________________________________________________________________________________

(Please send copies of last 12 months of progress notes, treatment summary, diagnostic test results)

6. Any additional information: ______________________________________________________________________

____________________________________________________________________________________________

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

Seizure 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 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-16, 12/09 [File: 1100.0.1] OMB control number 1652 - 0032; Expiration Date: 03/31/2016