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pdfHearing Further Evaluation
SSN: __ __ __ - __ __ - __ __ __ __
Candidate Name:
MEDICAL CONDITION:
This candidate is under consideration for a position as a Transportation Security Officer (Screener) (TSO) position at the Transportation Security Administration
(TSA). His/her pre-employment medical screening, including a medical history review on ___________________________, revealed the following:
Hearing Loss
Paperwork Reduction Act Statement
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 20 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.
CANDIDATE SECTION:
Candidate must complete Candidate section, including signature
Candidates will not receive further consideration in the TSO job application process if CHS does not receive ALL requested paperwork
within 60 days of the candidate’s initial medical screening
Candidate Signature: _______________________________________
Date: ____________________________
Any expenses incurred remain your responsibility and will not be reimbursed by CHS or TSA
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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 (Screener) Job Requirements Overview”
and determine candidate’s ability to perform this job in relation to the above indicated condition
All tests have been performed in an acoustic environment, meeting current ANSI standards
Yes
No
All testing equipment has been calibrated within one year to meet current ANSI standards
Yes
No
Candidate’s ear canals are free of wax or other occlusion
Yes
No
All measurements are monaural
Yes
No
* Measurements must be made monaurally in an audiometric sound field with the non-tested ear plugged and when necessary, effectively masked.
** When performing personal hearing aid testing, measurements must be expressed as real-ear aided response, with sound pressure levels appropriately
converted to hearing levels.
*** If candidate does not meet the standards listed below under “Hearing Results”, please test using a demonstration hearing aid to assess the candidate’s
ability to meet TSA hearing standards.
PURE TONE TESTS:
If amplified, please provide pure-tone results or real ear responses below. In order for this form to be complete, scores from the day of exam must be recorded
in the space below. GRAPHS WILL NOT BE ACCEPTED
WITHOUT HEARING AID: (Required only if candidate does not have / need hearing aid)
Right Ear
500
Left Ear
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
Air Conduction
Average of
500, 1000,
2000, 3000
WITH HEARING AID:
• CROS style hearing aid(s) are not accepted
• Please indicate if candidate was tested with his/her
Personal Hearing Aid(s)
Demonstration Hearing Aid(s)
•
If candidate requires amplification to meet hearing standards he/she should be tested using demonstration aids to assess his/her potential to meet
the TSA hearing standards, however, personal hearing aid test scores and proof of hearing aid purchase must be included for medical certification.
Right Ear
500
Left Ear
1000
2000
3000
4000
6000
500
1000
2000
3000
4000
6000
Air Conduction
Average of
500, 1000,
2000, 3000
HEARING RESULTS:
Right Ear
Left Ear
Less than or equal to 25db for the average of 500, 1000, 2000, and 3000 Hz in each ear?
Yes
No
Yes
No
Less than or equal to 45db at 4000 Hz and 6000 Hz in each ear?
Yes
No
Yes
No
Does candidate have any other identified hearing conditions?
Yes
No If yes, please explain ______________________________________________
______________________________________________________________________________________________________________________________
Physician Signature: ____________________________________________
Date: ____________________________
Please Print Physician Name: __________________________________________________________________________
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 800-638-8083 extension 19514. FAX # 703-288-5495
COMPREHENSIVE HEALTH SERVICES, 8810 Astronaut Blvd, Suite 145, Cape Canaveral, FL
FE Form Hearing 2006-0726
Page 1 of 2
Phone 800-638-8083 x19514, Fax 703-288-5495
Last Updated on: 7/26/2006
Hearing Further Evaluation
Candidate Name: ____________________________________________________ SSN: _______________________
Transportation Security Officer (Screener) Job Requirements Overview
1. A Transportation Security Officer (Screener) must be able to:
a)
b)
c)
d)
e)
f)
Repeatedly lift and carry at least 70 lbs. on a daily basis.
Walk and stand for prolonged periods of time (up to 3 hours).
Frequently bend and squat.
Have adequate sensation in both hands and all fingers.
Localize sounds and threats (respond to the spoken word and alarms in a noisy environment).
Work effectively and remain alert and calm in stressful situations (e.g., frustrated passengers, flight
deadlines, security incidents).
g) React to emergencies in a calm, focused, and coordinated manner.
h) Remain alert and vigilant at all times.
i) Be prepared for frequent assignment to irregular schedules including uncertain meal times and breaks.
j) Use and work in the vicinity of electromagnetic equipment (e.g., metal detectors and x-ray machines) for
prolonged periods of time.
k) Work closely with co-workers in a frequently crowded, noisy environment.
2. A Transportation Security Officer (Screener) also must have:
a) A consistent blood pressure of no more than 140/90.
b) A consistent pulse rate of no more than 90 bpm.
c) Good ambidextrous dexterity.
Physician Acknowledgment:
Based on my medical evaluation of only the specific medical condition for which this candidate was referred, and my
understanding of the above listed job requirements, this candidate:
Is capable of meeting the above requirements safely, efficiently and effectively.
Is NOT capable of meeting the above requirements safely, efficiently and effectively.
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.
AUTHORITY: 49 U.S.C. § 114(e). 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. Failure to provide your SSN may result in
a delay in determining your eligibility for employment as a TSO.
COMPREHENSIVE HEALTH SERVICES, 8810 Astronaut Blvd, Suite 145, Cape Canaveral, FL
FE Form Hearing 2006-0726
Page 2 of 2
Phone 800-638-8083 x19514, Fax 703-288-5495
Last Updated on: 7/26/2006
| File Type | application/pdf |
| File Title | Microsoft Word - FE Form Hearing 2006-0726.doc |
| Author | mgibson |
| File Modified | 2006-07-26 |
| File Created | 2006-07-26 |