Implanted Medical Device further evaluation

Candidate Name:

Implanted Medical Device
Explanation of Risk(s) Verification Form
SSN: __ __ __ - __ __ - __ __ __ __

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:
Implanted Medical Device
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.

PHYSICIAN INSTRUCTIONS:
This candidate has applied for a Transportation Security Officer (Screener) (TSO) position with the Transportation Security
Administration (TSA). During medical screening this candidate revealed having a pacemaker, deep brain stimulator, or other
such battery powered medically implanted device.
Transportation Security Officers (Screeners) routinely use or come into contact with electromagnetic equipment including, but
not limited to, X-ray machines, walkthrough magnetometers, handheld magnetometers and explosive trace detection devices.
These devices are used by multiple persons in a small, often confined working area.
Please discuss the following risks and any potential other risks that may be encountered or experienced working with or around
machinery with electromagnetic fields. The potential risks to persons with battery operated implanted medical devices include,
but are not limited to:
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Inhibited pacing which would be observed as random pauses in the paced heart rhythm
Pacing at an elevated rate which could be consistent or sporadic
Reversion to asynchronous mode that causes a fixed heart rate
Delivery of an inappropriately high voltage because the electromagnetic interference (EMI) was detected as an
arrhythmia
Failure to detect arrhythmias
Randomly or consistently inhibited pacing mechanism thus resulting in random pauses in the heart beat
Pacing may cause a consistent or sporadic increase in the heart rate pacing

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CANDIDATE ACKNOWLEDGEMENT:
Please acknowledge that you have received information regarding the risks of working around or with equipment with
electromagnetic fields and understand the potential risks by signing the acknowledgment below. You must sign this form in the
presence of your physician. You also understand that if you are employed or hired as a TSO that you will be required to
work with and around electromagnetic equipment.
________________________________ _________________________________ _______________________ __________
Candidate’s Signature

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Candidate’s Printed Name

Candidate’s SSN

Date

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

PHYSICIAN ACKNOWLEDGEMENT:
Your signature acknowledges that you have explained any potential risks to the candidate and that you have witnessed the
candidate signing acknowledgement of the potential risks.
________________________________ _________________________________ _______________________ __________
Physician’s Signature

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Physician’s Name Printed

Physician’s Area of Specialty

Date

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
Note: physician and candidate acknowledgement must BOTH be completed and signed

Fax # 703-288-5495
If unable to fax please call 800-638-8083 extension 19514
COMPREHENSIVE HEALTH SERVICES, 8810 Astronaut Blvd, Suite 145, Cape Canaveral, FL
FE Form Implanted Medical Device 2006-0726
Page 1 of 2

Phone 800-638-8083 x19514, Fax 703-288-5495
Last Updated on: 7/26/2006

Implanted Medical Device
Explanation of Risk(s) Verification Form
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 Implanted Medical Device 2006-0726
Page 2 of 2

Phone 800-638-8083 x19514, Fax 703-288-5495
Last Updated on: 7/26/2006