83i Med Q_83i_SuppStmt (FINAL 8-21-06)

Please read the instructions before completing the form. For additional forms or assistance in completing this form, contact your agency's Paperwork Clearance Officer. Send two copies of this form, the collection instrument to be reviewed, the Supporting Statement, and any additional documentation to: Office of Information and Regulatory Affairs, Office of Management and Budget, Docket Library, Room 10102, 725 17th Street NW, Washington, DC 20503.
Agency/Subagency originating request DHS/Transportation Security Administration		OMB Control Number b. None a. 1652-0032
Type of information collection (check one) a. New collection b. Revision of a currently approved collection c. Extension of a currently approved collection d. Reinstatement, without change, of a previously approved collection for which approval has expired e. Reinstatement, with change, of a previously approved collection for which approval has expired f. Existing collection in use without an OMB control number For b‑f, note Item A2 of Supporting Statement instructions		Type of review requested (check one) a. Regular b. Emergency ‑ Approval requested by: _____/_____/_____ c. Delegated Small entities Will this information collection have a significant economic impact on a substantial number of small entities? Yes X No
		Requested expiration date a. Three years from approval date b. Other Specify: ____/____
Title Transportation Security Officer (TSO) Medical Questionnaire
Agency form number(s) (if applicable) N/A
Keywords Government employees, Health, Health records, Medical.
Abstract This collection of information will assist the agency in ensuring that candidates under employment consideration for Transportation Security Officer (TSO) positions meet the qualification standards to successfully perform the functions of the position. The information will be collected from applicants for TSO (formerly screener) positions to evaluate a candidate’s current and past medical history including visual and aural acuity, physical coordination, and motor skills.
Affected public (Mark primary with "P" and all others that apply with "X") a. __P_ Individuals or households d. ___ Farms b. ___ Business or other-for-profit e. ___ Federal Government c. ___ Not-for-profit institutions f. ___ State, Local, or Tribal Government		Obligation to respond (Mark primary with "P" and all others that apply with "X") a. ___ Voluntary b. ___ Required to obtain or retain benefits c. _P_ Mandatory
Annual Recordkeeping and reporting burden		Annual reporting and recordkeeping cost burden (in thousands of dollars)
a. Number of respondents	_57,038____	a. Total annualized capital startup costs	_______0______
b. Total annual responses 1. Percentage of these responses collected electronically	_68,438____ _______0_____ %	b. Total annual cost (O&M)	_______0______
c. Total annual hours requested	_19,013____	c. Total annualized cost requested	_______0______
d. Current OMB inventory	_11,430____	d. Current OMB inventory	_______0______
e. Difference (+/‑)	__7,583____	e. Difference	_______0______
f. Explanation of difference 1. Program change (+/‑) 2. Adjustment (+/‑)	__7,583____ ____n/a____	f. Explanation of difference 1. Program change 2. Adjustment	_______0______ _______0______
Purpose of information collection (Mark primary with "P" and all others that apply with "X") a. ___ Application of benefits e. ___ Program planning or management b. ___ Program evaluation f. ___ Research c. ___ General purpose statistics g. _P_ Regulatory compliance d. ___ Audit		Frequency of recordkeeping or reporting (check all that apply) a. Recordkeeping b. Third party disclosures c. Reporting 1. On occasion 2. Weekly 3. Monthly 4. Quarterly 5. Semi‑annually 6. Annually 7. Biennially 8. Other (describe) One time per respondent
Statistical methods Does this information collection employ statistical methods? Yes No		Agency contact (person who can best answer questions regarding the content of this submission Name: ___Katrina Wawer_____________________ Phone: ___(571) 227-1995______________________

Certification for Paperwork Reduction Act Submissions On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9. NOTE: The text of 5 CFR 1320.9, and the related provisions of 5 CFR 1320.8(b)(3), appear at the end of the instructions. The certification is to be made with reference to those regulatory provisions as set forth in the instructions. The following is a summary of the topics, regarding the proposed collection of information, that the certification covers: (a) It is necessary for the proper performance of agency functions; (b) It avoids unnecessary duplication; (c) It reduces burden on small entities; (d) It uses plain, coherent, and unambiguous terminology that is understandable to respondents; (e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices; (f) It indicates the retention periods for recordkeeping requirements; (g) It informs respondents of the information called for under 5 CFR 1320.8(b)(3): (i) Why the information is being collected; (ii) Use of information: (iii) Burden estimate; (iv) Nature of response (voluntary, required for a benefit, or mandatory; (v) Nature and extent of confidentiality; and (vi) Need to display currently valid OMB control number: (h) It was developed by an office that has planned an allocated resources for the efficient and effective management and use of the information to be collected (see note in Item 19 of the instructions); (i) It uses effective and efficient statistical survey methodology; and (j) It makes appropriate use of information technology. If you are unable to certify compliance with any of these provisions, identify the item below and explain the reason in Item 18 of the Supporting Statement.

Signature of Senior Official or Designee

Date

1. Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information. (Annotate the CFR parts/sections affected).

TSA is requesting approval to revise this collection of information to comply with 49 U.S.C. 44935, which requires TSA to establish qualification standards for the employment of security screening personnel. With approval from OMB, TSA currently collects information via a Transportation Security Officer (TSO) Medical Questionnaire. TSA now seeks approval to make revisions to the form (and to adjust the title as a result of the conversion from Transportation Security Screeners to Transportation Security Officers on February 5, 2005). TSA also seeks approval to include additional supplemental medical forms, which are required in circumstances where additional medical information is needed to make a determination regarding the candidate’s qualifications for the TSO job. Only those TSOs who are required to undergo a follow-up medical exam will be required to bring a supplemental form (or forms) to the exam. For example, due to the physically demanding nature of the TSO job, it is important to ensure that individuals who have prior back injuries are evaluated thoroughly to ensure they can perform the TSO job safely and efficiently, without excessive risk of accident or injury to themselves or others. This additional information is provided by the candidates’ health care provider of choice and includes historical and other information needed to make a determination.

2. Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

This collection of information assists the agency in ensuring that candidates under employment consideration for Transportation Security Officer (formerly Screener) positions meet the qualification standards to successfully perform the functions of the positions. Information is collected through a medical questionnaire and supplemental forms. TSA deems this collection necessary to evaluate a candidate’s current and past medical history, including, visual and aural acuity, physical coordination, and motor skills to be able to: (a) distinguish on screening equipment monitors the appropriate imaging standard; (b) distinguish each color displayed on every type of screening equipment and explain what each color signifies; (c) hear and respond to the spoken voice and to audible alarms in an active checkpoint environment; (d) perform physical searches by efficiently and thoroughly manipulating and handling baggage containers, and other objects; (e) perform pat-downs or hand-held metal detector searches of individuals with sufficient dexterity and capacity to thoroughly conduct the procedures over an individual’s entire body; and (f) demonstrate a daily fitness for duty without impairment due to illegal drugs, sleep deprivation, medication, or alcohol.

A TSA contractor will facilitate receipt and processing of the supplemental forms. The variety of forms pertains to particular body systems and medical conditions, including cardiac, orthopedic, endocrine, vitals, etc. The form (or forms) a candidate’s health care provider will complete depends on the condition(s) revealed during a candidate’s initial medical evaluation. Thus, while all candidates reaching the medical evaluation portion of the selection process will be asked to complete a medical questionnaire, only candidates for whom additional information is needed will be asked to seek further evaluation from their health care provider and submit additional information through the further evaluation forms.

3. Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden. [Effective 03/22/01, your response must SPECIFICALLY reference the Government Paperwork Elimination Act (GPEA), which addresses electronic filing and record keeping, and what you are doing to adhere to it. You must explain how you will provide a fully electronic reporting option by October 2003, or an explanation of why this is not practicable.]

The collection of information from candidates under employment consideration for Transportation Security Officer positions is a manual collection technique at the current time. The questionnaire and supplemental further evaluation forms are filled out manually during the assessment process when other forms are filled out, thus, the manual method is most convenient for respondents and TSA. TSA is evaluating the option of automating the collection technique and has received a cost proposal in an effort to facilitate compliance with the Government Paperwork Elimination Act.

4. Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purpose(s) described in Item 2 above.

During the rapid hiring of Transportation Security Screeners in 2002 and until summer 2004 TSA used the SF-93, Report of Medical History, as the collection technique to ensure candidates under employment consideration for Transportation Security Screener positions met the qualification standards to successfully perform the functions of the position as described above. TSA with OMB approval, began using the Screener Medical Questionnaire (SMQ) instead of the SF-93. TSA has found the SMQ form more suitable as it collects the information necessary to assist the medical providers in making determinations regarding applicants’ medical and physical abilities to successfully perform the job without being overly intrusive.

5. If the collection of information has a significant impact on a substantial number of small businesses or other small entities (Item 5 of the Paperwork Reduction Act submission form), describe the methods used to minimize burden.

The collection of information does not have a significant impact on a substantial number of small businesses or other small entities. As described above, the medical questionnaire information is collected from candidates under employment consideration for Transportation Security Screener positions. Additional information is provided for some candidates by health care providers. However, this information is limited and does not have a significant impact on a substantial number of small businesses.

6. Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

The determination that candidates successfully meet the qualification requirements described above is essential to create and maintain a national workforce of skilled and medically qualified employees charged with protecting the Nation’s transportation systems by ensuring the freedom of movement for people and commerce. The security of the Nation’s transportation systems would be severely compromised if this collection is not conducted or is conducted less frequently.

7. Explain any special circumstances that require the collection to be conducted in a manner inconsistent with the general information collection guidelines in 5 CFR 1320.5(d)(2).

There are no special circumstances that require the collection to be conducted in a manner inconsistent with the general information collection guidelines in 5 CFR 1320.5(d)(2).

8. Describe efforts to consult persons outside the agency to obtain their views on the availability of data, frequency of collection, the clarity of instructions and record keeping, disclosure, or reporting format (if any), and on the data elements to be recorded, disclosed, or reported. If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency's notice, required by 5 CFR 1320.8(d) soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

TSA invited public comment on this information collection requirement, which was published in the Federal Register on April 19, 2006 (71 FR 20118). To TSA’s knowledge, no comments have been received in response to this notice.

TSA has also consulted with experts in job-related medical standards and applicant medical suitability determinations in developing this collection technique.

9. Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

TSA will not provide any payment or gift to respondents.

10. Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

TSA will maintain the information according to the Privacy Act, OPM/GOVT-10 System of Records if hired, or under the OPM/GOVT-5 System of Records if not hired. TSA will maintain the information in a secured area with access limited to authorized personnel whose duties require access.

11. Provide additional justification for any questions of sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private.

While some of the questions TSA is posing could be considered to be of a sensitive nature, TSA deems this collection necessary to evaluate a candidate’s medical suitability for the TSO job. While some of this information is commonly considered private, the collection is essential to ensure that the individuals performing TSA’s security mission are physically able to perform their duties safely, with minimal risk of injury to themselves or others, and in a manner that does not compromise security.

12. Provide estimates of hour burden of the collection of information.

Based on historical completion rates we estimated the hour burden based on the following logic:

• Questionnaire: There are an estimated 38,000 applicants who complete the SOMQ annually.

  • It takes approximately 20 minutes to complete, therefore would result in a burden of 12,667 hours.

• Supplemental: Of the 38,000 applicants, on average 1/3 of them will need to complete at least one further evaluation form, resulting in 11,400 applicants (38,000 X .3) and 19,038 Physicians (11,400 X 1.67) completing further evaluation forms

  • Not all applicants will be required to complete the further evaluation supplemental forms; some applicants need to complete multiple forms whereas others only need to complete one form. On average applicants need to complete 1.67 further evaluation forms per person. Because the issue or issues for which an applicant must undergo further evaluation may fall into different specialty areas, TSA assumes applicants would need to visit 1.67 physicians.

  • For 11,400 applicants it should take approximately take 5 minutes to complete their section of the form(s) resulting in a burden of 1,586.5 hours (11,400 X 1.67 forms X 5 min / 60 min per hour)

  • For 19,038 Physicians it should take approximately 15 minutes to complete their section of the form(s) resulting in a burden of 4,759.5 hours (19,038 X 15 min/60 min per hour)

  • This would result in a total further evaluation burden of 6,346 hours.

• Therefore, the current estimated annual reporting burden for the entire information collection is 19,013 hours.

Therefore, TSA estimates approximately 68,438 responses [38,000 SOMQ +11,400 (applicant FE)+19,038 (docs responding)].

13. Provide an estimate of the total annual cost burden to respondents or record keepers resulting from the collection of information.

There is no cost burden to the respondents.

14. Provide estimates of annualized cost to the Federal Government. Also, provide a description of the method used to estimate cost, and other expenses that would not have been incurred without this collection of information.

The annual operating costs include the following:

• Assessment team medical personnel to review and process the SMQ and FE forms ($2,397,204).

• Storage costs associated with the SMQ and FE forms ($4,860).

• Shipping costs from the medical provider sites to the review location and then to the storage facility ($147,420).

• Training for medical personnel to collect/review SMQ and FE forms ($6,757)

Therefore, TSA estimates the total annual costs to the Federal Government as a result of this information collection as $2,556,241.

15. Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I.

We are requesting a program change due to the inclusion of additional medical evaluation follow-up forms. By doing so, we have increased the respondent population.

16. For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

TSA will not publish the information collected.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate.

TSA is not seeking such approval and will display the expiration date for OMB approval of the information collection.

18. Explain each exception to the certification statement identified in Item 19, “Certification for Paperwork Reduction Act Submissions,” of OMB Form 83-I.

TSA is not seeking any exceptions to the certification statement identified in Item 19, OMB Form 83-I, Certification for Paperwork Reduction Act Submissions.

OMB 83‑I (10/95)