Diabetes Further Evaluation

Diabetes Further Evaluation
Candidate Name:

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:
… History of Diabetes

… Random Urine Positive Ketones
… Random Urine Positive Glucose
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

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In the past 4 weeks have you experienced any of the following? (Check all that apply)
□ Tingling or numbness in hands or feet
□ Sores that have healed slowly
□ Had blurry vision
□ Felt unusually thirsty

□
□
□
□

Shakiness, weakness or unusual drowsiness
Had any infections
Fast heart beat
Frequent urination (more than usual)

Candidate Signature: _______________________________________
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Date: ____________________________

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

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

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1.
2.
3.
4.
5.
6.
7.

Diagnosis: _________________________________________________ Date of diagnosis: _____________
Prognosis _______________________________________________________________________________
Date of last hospitalization ______________________________________________________
What was the HgbA1c (within last 3 months) test results: _______________________________
Is there any evidence of significant target organ damage: … Yes
… No
How many times has the candidate had blood sugar irregularities in the past year: ___________
What was the date and results from the latest fasting blood sugar test? ___________________________________
____________________________________________________________________________________________

8. What medication is the candidate currently taking for diabetes?
Medication:
Dose:

Frequency:

:

______________________________________________________________________________________________
______________________________________________________________________________________________
MUST provide supporting documentation; including progress notes and diagnostic test results for the last 12 months.
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 Diabetes 2006-0726
Page 1 of 2

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

Diabetes 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 Diabetes 2006-0726
Page 2 of 2

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