Orthopedic further evaluation

Candidate Name:

Orthopedic Further Evaluation
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: _______________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
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:
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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

1.
2.
3.
4.
5.

Have you ever missed work/school due to your orthopedic injury/surgery?
□ Yes
□ No
Do you currently have any pain associated with your orthopedic condition?
□ Yes
□ No
Do you take medication for the pain?
□ Yes
□ No
If yes, what medication and how often do you take it? __________________________________
Do you have difficulty with any of the following and if so explain: ___________________________________________
□ Standing for up to 3 hours □ Sitting for up to 3 hours □ Stooping / bending
□ Lifting heavy objects on regular basis (_____ lbs)

Candidate Signature: _______________________________________

Date: ____________________________

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

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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

HEALTH CARE PROVIDER SECTION:

1. Diagnosis: ______________________________________________ Date of diagnosis: ______________________
2. Prognosis ____________________________________________________________________________________
3. What medication(s) is the candidate currently taking for this condition?
Medication:
Dose:
Frequency:
:
______________________________________________________________________________________________
______________________________________________________________________________________________
4. Date of Surgery (If applicable): _________________________________________________________ (mm/dd/yyyy)
5. List any physical restrictions: ______________________________________________________________________
6. Any additional information: ______________________________________________________________________
It is very important to send supporting documentation – 12 months of progress notes, diagnostic test results,
treatment summary and CURRENT orthopedic evaluation to CHS for Medical Director’s review. Please complete the
attached orthopedic assessment and “Transportation Security Officer (Screener) Job Requirements Overview” pages.
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 800-638-8083 extension 19514.

Fax # 703-288-5495
COMPREHENSIVE HEALTH SERVICES, 8810 Astronaut Blvd, Suite 145, Cape Canaveral, FL
FE Form Orthopedic 2006-0726
Page 1 of 3

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

Orthopedic Further Evaluation
Candidate Name:

SS#: __ __ __ - __ __ - __ __ __ __

ORTHOPEDIC ASSESSMENT
Please perform the orthopedic screening in relation to the candidate’s ability to handle, search and repeatedly lift baggage
weighing up to 70 lbs on a daily basis, and continuously stand or ambulate for up to 3 hours.
Record “NORMAL” if the test is completed successfully. Record “ABNORMAL” if unsuccessful.
Provide description of the limitations as seen during this screening process.
Observations / Comments
Required if abnormal

1. Gait

Have the candidate ambulate towards you in a normal
manner
Have candidate repeat on his/her toes
Have candidate repeat on his/her heels

2. Hip, Knee, Ankle

Ask candidate to stand with feet shoulder width apart
facing examiner.
Ask candidate to squat down and return to the starting
position.
Repeat as needed to fully assess.

3. T + L Spine

Ask candidate to bend at waist with knees extended
and attempt to touch the floor or his/her toes
Repeat as needed to fully assess ability.

(Thoracolumbar flexion &
extension

4. Balance, Shoulder
(Left – Hyperabduction, supination,
pronation)

Ask candidate to stand on left leg and bring his/her
arms from his/her side over his/her head and touch the
palmar surfaces of his/her hands together and then
return arms to the original starting position
Repeat as needed to fully assess

(Right Hyperabduction, supination,
pronation)

Ask candidate to stand on right leg and bring his/her
arms from his/her side over his/her head and touch the
palmar surfaces of his/her hands together and then
return arms to the original starting position
Repeat as needed to fully assess

6. Elbow Flexion &
Extension

Ask candidate to fully flex and extend elbows
Repeat as needed to fully assess

7. Hand

Ask candidate to flex elbows 90 degrees with hands in
a pronated starting position and open and close hands
Determine the A/ROM of the applicable joints
Assess whether the candidate has any amputations

5. Balance, Shoulder

(A/ROM all joints and amputation
check)

8. Wrist
(A/ROM all joints and amputation
check)

Ask candidate to flex elbows 90 degrees with hands in
a pronated starting position
Ask candidate to perform A/ROM of his/her wrists in all
available planes (i.e. flex, ex RD, UD)
Repeat as needed to fully assess

9. Opposition

Ask candidate to touch the tip of his/her thumb to each
fingertip
Repeat as needed to fully assess

10. C-Spine

Ask candidate to perform A/ROM of c-spine in all
available planes in standing position (i.e. flex, extend
LSB, RSB, L Rotate, R Rotate)
Repeat as needed to fully assess

(A/ROM All Planes)

COMPREHENSIVE HEALTH SERVICES, 8810 Astronaut Blvd, Suite 145, Cape Canaveral, FL
FE Form Orthopedic 2006-0726
Page 2 of 3

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

Orthopedic 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 Orthopedic 2006-0726
Page 3 of 3

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