C
Cancer
Further Evaluation |
MEDICAL CONDITION: |
This candidate is under consideration for a position as a Transportation Security Officer (TSO) position at the Transportation Security Administration (TSA). His/her pre-employment medical screening on ___________________, including a medical history review, revealed the following: History of Cancer |
Paperwork Reduction Act Statement |
The Transportation Security Administration (TSA) requires physical/medical examinations prior to an individual’s appointment to a TSA Security Officer position. TSA uses this form 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 position. It is estimated that the total average burden per response associated with this form is approximately 5 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 for this collection is OMB control number 1652-0032, which expires 3/31/2016. |
CANDIDATE SECTION: |
_______________________________________________________________________________________________
Candidate Signature: _______________________________________ Date: ____________________________
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HEALTH CARE PROVIDER SECTION: |
Medication: Dose: Frequency: :
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
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 866-416-5928. Fax 703-288-5495 |
C
Cancer
Further Evaluation
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Transportation Security Officer (TSO) Job Overview from Vacancy Announcement on www.usajobs.gov
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Physician Review |
Based on my findings and opinions presented in the Health Care Provider Section of this form, this candidate:
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.
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PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. 44935 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.
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TSA Form 1130B-1, 12/09 [File: 1100.0.1] OMB control number 1652 - 0032; Expiration Date: 03/31/2016
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Candidate Name: SS# |
Author | Kaye Whitson |
File Modified | 0000-00-00 |
File Created | 2021-01-24 |