Form TSA-1915 CMSDT Program Attendance Roster

C MSDT Program Attendance Roster

INSTRUCTIONS: Please complete all fields, as appropriate. Please print legibly.

TO BE COMPLETED BY TRAINEE					TO BE COMPLETED BY TRAINER
Name	Airline Affiliation	Airline ID #	2nd ID #	Contact Info Mailing Address/Email/Phone #	Day 1	Day 2	Day 3	Certification Rec’d?
								Yes No
								Yes No
								Yes No
								Yes No
								Yes No
								Yes No
								Yes No
								Yes No

PRIVACY ACT STATEMENT: Authority: Title 49, United States Code, sections 114 and 44918. Principle Purpose(s): TSA is collecting information from airline crew members who have volunteered to participate in TSA-sponsored crew member self-defense training. Routine Use(s): TSA will use the information you provide to confirm your eligibility for this training, to keep track of which individuals have completed the training, and for program management and evaluation purposes. You are not required to participate in this training or provide the requested information, however, if you do not provide the requested information you may not be permitted to participate in the training. Disclosure: This information may be disclosed to TSA contractors who are assisting TSA with the training, to the Federal Aviation Administration for purposes of administering this and other civil aviation safety and security programs, or to your employer if relevant to your eligibility for employment. Information collected will become part of a TSA Privacy Act system of records named DHS/TSA 018, a copy of which is publicly available from TSA upon request.

PAPERWORK REDUCTION ACT STATEMENT: Through this information collection, TSA is gathering information about you to confirm your attendance at TSA’s crew member self-defense training course. The public burden for this collection of information is estimated to be five minutes. This is a voluntary collection of information. An agency may not conduct or sponsor, and persons are not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number assigned to this collection is 1652-0028, which expires mm/dd/yyyy.

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TSA Form 1915, July 2008 OMB Control No. 1652-0028 Expires 4/30/2015