Transportation Security Officer Medical Questionnaire

SMQ Candidate Version 2.1 (7-24-06)

Transportation Security Officer Medical Questionnaire

OMB: 1652-0032

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1652-0032 can be found here:

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For Official Use Only
TSA Security Officer Medical Questionnaire

TRANSPORTATION SECURITY OFFICER
MEDICAL QUESTIONNAIRE
PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS
The Transportation Security Administration (TSA) requires physical/medical examinations prior to an individual’s appointment to a TSA Security Officer (Screener) position.
TSA uses the following medical documents 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 (Screener) position. It is estimated that the total average burden per response associated with
this collection is approximately 18 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 assigned to this collection is OMB 1652-0032, which expires 09/08.
Failure to submit to the examination or failure to make full and open disclosure of any current or past medical conditions, including incomplete, misleading or inaccurate
information, may be grounds for disqualification from TSA employment, or disciplinary or adverse action if employed.
49 U.S.C. § 114 (e) authorizes the collection of this information. TSA will not disclose this information other than for routine uses as identified in OPM system of records,
OPM/GOVT-10 if hired, or OPM/GOVT-5 if not hired. Upon written authorization from the individual, the agency may release a copy of the medical record. The individual
should forward a notarized letter to the agency identifying to whom the information may be released. Disclosure of your SSN is voluntary. This information is used to identify
and separate individuals with similar or identical names or initials. If you do not provide your SSN or any other information requested, we cannot process your application.

INSTRUCTIONS
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.

DEMOGRAPHIC INFORMATION
Name (Print):

______________________________________

Address:

______________________________________

Social Security #:

___ ___ ___ - ___ ___ - ___ ___ ___ ___

______________________________________

Sex: Male _______ Female _______

Home Phone #:

(__ __ __) __ __ __ - __ __ __ __

Date of Birth: _____/_____/________

Work Phone #:

(__ __ __) __ __ __ - __ __ __ __

Other Phone #:

(__ __ __) __ __ __ - __ __ __ __

(mm / dd / yyyy)

Height:

______Feet ______Inches

Weight:

______lbs

Best Time to Call: ______________________________________

GENERAL INFORMATION
1. Have you been refused employment, dismissed from a job, or unable to
stay in school due to any medical condition or excessive absenteeism?

1. Yes_____

No______

If yes, please list each medical condition and record the year of the refusa:

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:

3. Have you had, or have you been advised to have, any operations?

3. Yes_____

No______

4. Yes_____

No______

5. Yes_____

No______

If yes , describe what type of operation and indicate date if appropriate

4. Have you been treated at any type of hospital in the last 10 years?
If yes , specify when and reason for treatment:

5. Have you ever had any illness, injury, or condition (including learning
disability, attention deficit disorder, etc.) other than those already noted
above?

Don't Know ______

If yes , specify medical condition and when you were treated

SMQ Candidate Version 2.1 Updated 07/14/2006
Page 1 of 6

Candidate Initials _________

For Official Use Only
TSA Security Officer Medical Questionnaire

GENERAL INFORMATION (continued)
6. Have you consulted or been treated by clinics, physicians, healers, or
6. Yes_____ No______
other practitioners within the past year for anything other than minor
illnesses?
If yes , provide an explanation and the name of doctor consulted and/or the hospital/clinic

7. Have you ever been rejected for military service or law enforcement
position(s) because of physical, mental, or other medical reasons?
If yes , give date and reason for rejection:

7. Yes_____

No______

8. Have you ever been discharged from military service or a law
8. Yes_____ No______
enforcement position because of physical, mental, or other reasons?
If yes , give date and reason. If military discharge, list type (e.g., honorable, other than honorable, for unfitness, unsuitability):

9. Have you ever received a pension or compensation for a disability or
work related injury or illness?
If yes , complete the chart below for each occurrence:

Disability

Year
Disability
Granted

Disability related to which body system?
Check one.

% Disability
Granted

9. Yes_____

No______

Duration of Disability
(Years/Months)

Is disability
permanent?
(Yes/No)

Musculoskeletal
Mental Health
Other
Musculoskeletal
Mental Health
Other
Musculoskeletal
Mental Health
Other

1
2
3

10. Do you have a valid driver's license?

10. Yes_____

No______

11. Are you taking any prescription medications?
11. Yes_____ No______
If yes , list all current prescription medications and check the box that best describes how often you take each medication
Name of Medication

Daily

Weekly

Monthly or Less

VISION:
1. Do you have a total loss of vision in your right eye?

1. Yes_____

No______

2. Do you have a total loss of vision in your left eye?

2. Yes_____

No______

3. Have you had any type of eye surgery (such as Lasik,
cataracts, etc.) in the past year?

3. Yes_____

No______

SMQ Candidate Version 2.1 Updated 07/14/2006
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Candidate Initials _________

For Official Use Only
TSA Security Officer Medical Questionnaire

MEDICAL HISTORY
HEARING:
1. Do you have a total loss of hearing in your right ear?

1. Yes_____

No______

Don't Know ______

2. Do you have a total loss of hearing in your left ear?

2. Yes_____

No______

Don't Know ______

3. Do you wear hearing aids?
If yes, is it a CROS style hearing aid?

3. Yes_____
Yes_____

No______
No______

Don't Know ______

1. Chest pains
If yes, has your doctor prescribed heart medication for this?

1. Yes_____
Yes_____

No______
No______

Don't Know ______

2. Palpitations (rapid or skipped heart beat)
If yes, are you receiving treatment?

2. Yes_____
Yes_____

No______
No______

Don't Know ______
Don't Know ______

3. Heart murmur
If yes, has anyone ever recommended heart valve replacement?

3. Yes_____
Yes_____

No______
No______

Don't Know ______
Don't Know ______

4. Heart valve replacement

4. Yes_____

No______

5. Past history or diagnosis of heart disease

5. Yes_____

No______

6. Coronary bypass surgery or other heart surgery

6. Yes_____

No______

7. Heart attack or stroke

7. Yes_____

No______

8. Abnormal EKG or stress test result

8. Yes_____

No______

9. Pacemaker or implanted defibrillator
a. Pacemaker?
b. Implanted defibrillator?

9. Yes_____
a. Yes_____
b. Yes_____

No______
No______
No______

10. High blood pressure

10. Yes_____

No______

Don't Know ______

11. Circulatory problems (e.g., Raynaud's disease, swelling of ankles, leg
pains, numbness in feet or hands)

11. Yes_____

No______

Don't Know ______

12. Cramps in legs

12. Yes_____

No______

13. Phlebitis or blood clots

13. Yes_____

No______

CARDIOVASCULAR:

RESPIRATORY:

Have you EVER had or experienced any of the following?

1. Problems breathing, wheezing, persistent cough or shortness of breath
2. Bronchitis
3. Blood in sputum or when coughing
4. Past history or diagnosis of lung disease
5. History of tuberculosis
6. Positive TB test
7. Asthma

GASTROINTESTINAL:

1. Yes_____ No______
If yes , how long ago? ____________
2. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________
3. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________
4. Yes_____ No______
If yes , how long ago? ____________
5. Yes_____ No______
If yes , how long ago? ____________
6. Yes_____ No______
If yes , how long ago? ____________
7. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________

Have you EVER had or experienced any of the following?

1. Persistent stomach or abdominal pain

1. Yes_____ No______
If yes , how long ago? ____________
2. Yes_____ No______
If yes , how long ago? ____________
3. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________

2. Persistent diarrhea or constipation
3. Blood in stool

HEPATIC:

Don't Know ______

Have you EVER had or experienced any of the following?
1. Liver disease, jaundice or history of cirrhosis

1. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________
2. Yes_____ No______ Don't Know ______
If yes , how long ago? ____________

2. Hepatitis

SMQ Candidate Version 2.1 Updated 07/14/2006
Page 3 of 6

Candidate Initials _________

For Official Use Only
TSA Security Officer Medical Questionnaire

MEDICAL HISTORY (continued)
MUSCULOSKELETAL / ORTHOPEDIC:

Have you EVER had or experienced any of the following?

1. Amputated hand or missing hand

1. Yes_____

No______
No______

2. Any other amputation (e.g., leg, finger, toe)

2. Yes_____

3. Back pain
a. How often do you experience it?
b. How often do you take medication for your pain?

3. Yes_____ No______
a. Frequently ____ Occasionally ____
b. Frequently ____ Occasionally ____ Never ____

4. Back surgery

4. Yes_____

No______

5. Back injury

5. Yes_____

No______

6. Joint pain or swelling

6. Yes_____

No______

7. Loss of joint or limb movement

7. Yes_____

No______

8. Loss of strength or muscle weakness

8. Yes_____

No______

9. Difficulty walking

9. Yes_____

No______

10. Difficultly bending, stooping or squatting

10. Yes_____

No______

11. Difficulty reaching overhead, moving arms in all directions at shoulders

11. Yes_____

No______

12. Arthritis, rheumatism, bursitis or gout

12. Yes_____

No______

13. Bone, joint, or other deformity

13. Yes_____

No______

14. Foot problems (aching, pain when walking in bare feet)

14. Yes_____

No______

15. Any orthopedic surgery within the past two years

15. Yes_____

No______

16. Any neck (cervical spine) surgery

16. Yes_____

No______

17. Any neck (cervical spine) problems or disorder

17. Yes_____

No______

18. Any fracture(s) with symptoms and/or abnormal range of motion

18. Yes_____

No______

19. Plate, pin, or rod in any bone

19. Yes_____

No______

Don't Know ______

20. Check the statement below that best describes how long you can sit continuously without standing or walking:
I am physically able to sit continuously without taking a break for a total of:
Less than 1 hour in an 8-hour workday
At least 1 to 2 hours in an 8-hour workday
At least 3 to 4 hours in an 8-hour workday
At least 5 to 6 hours in an 8-hour workday
21. Check the statement below that best describes how long you can stand and walk continuously without sitting or leaning
against a table or wall:
I am physically able to stand and walk continuously without taking a break for a total of:
Less than 1 hour in an 8-hour workday
At least 1 to 2 hours in an 8-hour workday
At least 3 to 4 hours in an 8-hour workday
At least 5 to 6 hours in an 8-hour workday
22. Do you have any lifting restrictions?
If yes, what is the maximum weight you are allowed to lift?

22. Yes_____

No______
pounds

23. Place a check next to the response that best describe how often you lift and/or carry objects for each weight category:
Lift and/or carry (including upward pulling) a maximum of:
Never / Rarely
Occasionally
Weight
0 to 2 times per year

30 pounds
50 pounds
70 pounds

1 to 2 times per month

Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________

Frequently
Once per week or more

Frequently
Frequently
Frequently

24. How often do you participate in each of the following activities?
Weight
Climb (Stairs)
Stoop/Bend/Squat
Kneel

Never / Rarely

Occasionally

Frequently

0 to 2 times per year

1 to 2 times per month

Once per week or more

Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________
Never or Rarely______ Occasionally _________

25. If you have a limitation performing any of the tasks listed below,
place a check in the box (right, left) that corresponds to the side of
your body with the limitation. Otherwise, check "No Limitations".
a.
b.
c.
d.

Frequently
Frequently
Frequently

Limitations
Right
Left

No
Limitations

Can handle or pick up objects from a table with fingers
Can feel objects with fingers and hands (sensation)
Can touch finger tips to palm to make a fist
Can bend elbow and touch fingers to shoulder

SMQ Candidate Version 2.1 Updated 07/14/2006
Page 4 of 6

Candidate Initials _________

For Official Use Only
TSA Security Officer Medical Questionnaire

MEDICAL HISTORY (continued)
ENDOCRINE:
1.
2.
3.
4.

Have you EVER had or experienced any of the following?
Diabetes
1.
Thyroid disease
2.
Anemia
3.
Blood disorder
4.

Yes______
Yes______
Yes______
Yes______

No______
No______
No______
No______

Don't Know
Don't Know
Don't Know
Don't Know

______
______
______
______

NEUROLOGICAL:
Have you EVER had or experienced any of the following?
1. Localized weakness, numbness, tingling, or loss of sensation in hands,
1. Yes______ No______
legs, or feet
If yes , how long ago? ____________
2. Yes______ No______ Don't Know
If yes , how long ago? ____________
3. Yes______ No______ Don't Know
If yes , how long ago? ____________
4. Yes______ No______
If yes , how long ago? ____________
5. Yes______ No______ Don't Know
If yes , how long ago? ____________
6. Yes______ No______
If yes , how long ago? ____________
7. Yes______ No______
If yes , how long ago? ____________
8. Yes______ No______ Don't Know
If yes , how long ago? ____________
9. Yes______ No______
If yes , how long ago? ____________

2. Seizures
3. Tremors or shakiness
4. Fainting or dizziness
5. Head injury
6. Wear a brace or back support
7. Frequent or severe headaches
8. Nerve injury
9. Paralysis

PSYCHOLOGICAL:
Have you EVER had or experienced any of the following?
1. Counseling or psychiatric consultation
1. Yes______ No______
If yes , how long ago? ____________
2. Episodes of depression
2. Yes______ No______ Don't Know
If yes , how long ago? ____________
3. Periods of nervousness or anxiety
3. Yes______ No______ Don't Know
If yes , how long ago? ____________
4. Prescribed medication for a mental health condition
4. Yes______ No______ Don't Know
If yes , how long ago? ____________
5. History of alcoholism or alcohol use
5. Yes______ No______ Don't Know
If yes , how long ago? ____________
6. History of substance or drug use
6. Yes______ No______ Don't Know
If yes , how long ago? ____________
7. Suicide attempt or plans
7. Yes______ No______
If yes , how long ago? ____________

______
______

______

______
______
______
______
______

GENERAL HISTORY
Answer the following questions:
1. Have you had an organ transplant?
2. Are you currently using, or have you in the past used, any narcotic
medication or other prescription painkiller?
3. Are you currently using, or have you in the past used, sedating
medication or tranquilizers?
4. Do you currently have or in the past had a hernia?
a. Has it been surgically repaired?
b. Date of repair? ___________
5. Do you have any skin problems/disease (e.g., urticaria, eczema,
dermatitis, psoriasis)?
6. Do you currently have or in the past had cancer?
a. Type of cancer? _________________________________________

1. Yes______ No______
2. Yes______ No______
3. Yes______ No______

Don't Know ______

4. Yes______ No______
a. Yes______ No______

Don't Know ______

5. Yes______ No______

Don't Know ______

6. Yes______ No______

b. Date of diagnosis? _______________________________________
c. Date of last treatment? ____________________________________
7. Do you have narcolepsy or a sleep disorder?
8. Do you use tobacco?

7. Yes______ No______
8. Yes______ No______

Don't Know ______

SMQ Candidate Version 2.1 Updated 07/14/2006
Page 5 of 6

Candidate Initials _________

For Official Use Only
TSA Security Officer Medical Questionnaire

GENERAL HISTORY (continued)
9. Check the statement below that best describes your ability to lift and carry:
I affirm that I am physically able to pick up and carry a distance of
25 feet (for example, the distance to cross a two-lane street):
30 lbs. (for example, 2 cases of 12oz. soft drinks -- 24 cans in each case)
50 lbs. (for example, 3 cases of 12oz. soft drinks -- 24 cans in each case)
70 lbs. (for example, 4 cases of 12oz. soft drinks -- 24 cans in each case)
10. What is your present activity level?
Check the level of activity listed below that best describes how often you participate in each of the activities:
Activity

Never/Rarely

Occasionally

Frequently

0 to 2 times per year

1 to 2 times per month

Once per week or more

Walk 2 miles continuously