TSA Form 1915A CMSDT LIMITED ASSUMPTION OF RISK AND WAIVER OF RESPONSIB

OMB Control Number: 1652-0028
Expires: 07/31/2018

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration
CMSDT LIMITED ASSUMPTION OF RISK AND WAIVER OF RESPONSIBILITY

INSTRUCTIONS: All participants of the Crew Member Self Defense Training Program (CMSDT) shall read and acknowledge the contents of
the Section I, Acknowledgment of "Limited Assumption of Risk and Waiver Responsibility." The participant shall enter their airline name, badge
number, print name and sign in Section II. Forms shall be completed and submitted the day of the training event to the CMSDT instructor.
Competed forms shall be stored in accordance with TSA File Code 3500.13.
SECTION I. Acknowledgment of Limited Assumption of Risk and Waiver of Responsibility
In order to participate in the Transportation Security Administration (TSA) Office of Law Enforcement/Federal Air Marshal Service (OLE/FAMS)
self-defense training for crew members ("Training") you must read and complete this Limited Assumption of Risk and Waiver of
Responsibility' in its entirety.
Location of Training
Date of Training
I, the undersigned, understand that OLE/FAMS has taken all reasonable steps to minimize all risks to the participants in the Training, but is
unable to completely guarantee that no injury or other harm will come to me or my possessions. Participation in the Training is voluntary in
nature and entails certain risks, some of which are directly related to being in a training facility and/or simulated aircraft/terminal/facility
environment. These risks include, but are not limited to, a slip or fall, fall over obstacles, injury occurring while engaged in training exercises
including (but not limited to) simulated combat with the use of simulated weapons, injury occurring from physical exertion, or the occurrence of
some other unforeseeable accident.
I further understand that it is my responsibility to notify a designated representative of TSA if a participant becomes injured or is behaving in an
unsafe manner during the Training. I fully understand and accept these risks associated with participation in Training. I also hereby agree to
hold harmless and make no claim of any description including claims, actions, suits, procedures, costs, expenses, damages and liabilities
against the United States, its officers and employees, and the site owners for any loss or damages suffered in the course of my participation that
arise from the risks inherent in this activity. This agreement does not extend to injuries or losses (other than those arising from or related to the
inherent risks) proximately caused by the negligent or wrongful act or omission of an employee of the Government, acting within the scope of
employment, to the extent such claims are authorized and governed by the Federal Tort Claims Act.
I understand that this release will be binding upon me, my estate, and my heirs, representatives, and assigns. I further confirm that I understand
that the activities of a typical Training event can involve a good deal of physical activity, and I am in good physical health and do not suffer from
any heart condition or other ailment or physical disability that would impair my ability to participate in the events or place me in undue health
jeopardy. I understand that OLE/FAMS and the Lead Training Officer or designee will attempt to understand and work with the needs of
individuals attending this training; that I am not obliged to participate in the Training if I do not desire to do so; and that I may elect not to
participate. I have notified the Lead Training Officer prior to the start of class, if I have any medical condition or other special circumstances that
may affect my ability to participate safely in this training.
I agree to follow all the rules of safety given to me by my Instructor(s). Additionally, I agree to allow TSA to use any photographs or videos of me
taken at events or functions for the purpose of presenting training to other flight or cabin crews or for other TSA training.
I have read this Limited Assumption of Risk and Waiver of Responsibility carefully, and understand that by signing this form I am agreeing on
behalf of myself, my estate, my heirs, representatives, and assigns not to sue or seek other legal actions against the United States, the
Department of Homeland Security (DHS), the TSA OLE/FAMS, or any of their officers, site owners or transportation carriers providing training
facilities, or any of the insurers of the aforementioned parties for any loss or damages suffered in the course of my participation including injury
or death except as expressly provided herein.
SECTION II. Participant Information and Signature
Participant's Airline Carrier
Participant's Badge Number
Participant's Name (Printed)
Participant Signature
Date of Signature
PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114. PRINCIPAL PURPOSE(S): To document your acknowledgment of the limited assumption of risk and waiver
of responsibility in conjunction with your participation in the Crew Member Self Defense Training Program. ROUTINE USE(S): This information may be shared with
educational institutions or training facilities for purposes of enrollment and verification of attendance and performance, or for routine uses identified in the Department of
Homeland Security's system of records notice, DHS/ALL-003 Department of Homeland Security General Training Records. DISCLOSURE: Voluntary; failure to furnish the
requested information may result in an inability to approve you for participation in the Crew Member Self Defense Training Program.
PAPERWORK REDUCTION ACT STATEMENT: Through this voluntary collection of information, 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. An agency may not conduct or sponsor,
and a person is 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 07/31/2018. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions
for reducing this burden to TSA PRA Officer, 601 S. 12th Street, Arlington, VA 20598-6011. ATTN: PRA 1652-0028.

TSA Form 1915A (3/18) rev. [File: 3500.13]

Previous editions of the form are obsolete.

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