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C
Drug
or Alcohol Use Further Evaluation
andidate
Name:
Last 4 Digits of SSN: __ __ __ __
|
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, including a medical history
review on ____________________, revealed the following: □
History
of substance/drug abuse □
History
of alcohol abuse
|
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.
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CANDIDATE
SECTION:
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Candidate
must complete Candidate section, including signature
Candidate
will
not
receive further consideration in the TSO job application process
if CHS does not receive ALL requested paperwork within 90 days of
the candidate being placed on Further Evaluation for the position
Date
of last drug use: ______________(mm/dd/yyy) Date of last
alcohol use: ________________(mm/dd/yyy)
List
specific substance(s):
_______________________________________________________________
Current
medication being taken:
____________________________________________________________
Length
of current sobriety: Drugs
________________________Alcohol_________________________
Have
you ever attended a treatment program for alcohol or drugs ?
□
Yes
□
N o
If
yes, for each program provide length of program: ______________
Date ____________ For what condition ?
Did
you graduate? □
Yes □
No If more than one program, please provide information on back
of sheet.
5.
Are you attending or have you attended a support group?
□
Yes
□
No
If
yes, for what condition? _______________ Start date:
_____________ End date: ______________
Still
attending? □
Yes □
No
Candidate
Signature: _______________________________________ Date:
____________________________
|
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 Job Requirements Overview”
and determine candidate’s ability to perform this job in
relation to the above indicated condition
Diagnosis:
_________________________________________________ Date of
diagnosis: _____________
Prognosis
_______________________________________________________________________________
What
medication is the candidate currently taking for drug or alcohol
use?
Medication:
Dose:
Frequency:
:
______________________________________________________________________________________________
______________________________________________________________________________________________
Treatment
plan
__________________________________________________________________________
________________________________________________________________________________________
Is
the candidate compliant with the treatment plan? □
Yes □
No
Has
the candidate had any positive drug / alcohol test results in the
past year? □
Yes
□
No
State
condition(s) and number of positive tests for each condition:
Drug __________ Alcohol __________
Physician/Counselor
Signature: _____________________________________ Date:
_____________________________
Printed
Name: ______________________________________ Credential / Title:
________________________________
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
|
Drug or Alcohol Use
Further Evaluation
Candidate Name:
Last 4 Digits
of SSN: __ __ __ __
|
Transportation Security Officer (TSO)
Job Overview
from
Vacancy Announcement on www.usajobs.gov
A
TSO must be willing and able to:
Repeatedly
lift and carry up to 70 pounds;
Continuously
stand for anywhere between one (1) to four (4) hours without a
break to carry out screening functions;
Walk
up to two (2) miles during a shift;
Continuously
and effectively interact with the public, giving directions and
responding to inquiries in a reasonable tone and manner;
Maintain
focus and awareness and work within a stressful environment which
includes noise from alarms, machinery, and people, distractions,
time pressure, disruptive and angry passengers, and the
requirement to identify and locate potentially life threatening
devices and devices intended on creating massive destruction; and
Make
effective decisions in both crisis and routine situations.
TSO
medical standards include but are not limited to:
Distance
vision correctable to 20/30 or better in the best eye and 20/100
or better in the worse eye;
Near
vision correctable to 20/40 or better binocular;
Color
perception (e.g., red, green, blue, yellow, orange, purple,
brown, black, white, gray). Note: color filters (e.g., contact
lenses) for enhancing color discrimination are prohibited;
an
average hearing loss of 25 decibels (ANSI) at 500, 1000, 2000 and
3000 Hz in each ear, and
single
reading of 45 decibels at 4000 and 6000 Hz in each ear;
Adequate
joint mobility, dexterity and range of motion, strength, and
stability to repeatedly lift and carry up to 70 pounds; and
Blood
pressure not to exceed 140 / 90.
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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/Counselor
Signature: ___________________________________ Date:
____________________
Please
Print Physician/Counselor Name: ________________________
Credential/Title: __________________
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.
|
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.
Page
1
of 2
TSA
Form 1130B-5, 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 |