Form TSA Form 1133-3 TSA Form 1133-3 Practical Exercise Performance Requirements

DEPARTMENT OF HOMELAND SECURITY

Transportation Security Administration

PRACTICAL EXERCISE PERFORMANCE REQUIREMENTS

OMB Control Number: 1652-0043 Expiration Date: 07/31/2019

INSTRUCTIONS: Your patient is undergoing evaluation by the Federal Air Marshal Service Medical Program pursuant to either an application for employment or determination of fitness for duty. We request that you complete this form to assist us in our evaluation. Unless directed by the FAMS Medical Programs Section, this form may be completed by an Advanced Practice Registered Nurse (APRN). For purposes of this examination, please do not include any genetic information, including family medical history or the results of any genetic testing, with any medical records/ documentation you provide. NOTE TO MEDICAL EXAMINER: Please do not collect any genetic information provided by the examinee. Practical Exercise Performance Requirements (PEPR) are physical activities related to law enforcement tasks, e.g., conducting searches and making arrests. Please delineate if your patient is able to (Yes) or is unable to (No) perform the following tasks. N/A may be used if a localizing condition does not affect this ability.
Section I. Healthcare Provider's Evaluation
Essential Job Tasks and Performance Requirements	Yes	No	N/A
1. Lift/Carry
Without assistance, lift and carry individual (e.g., subject) resisting arrest to another area or out of aircraft.
Lift baggage into or out of aircraft overhead compartment.
Without assistance, lift and carry objects weighing 30 to 50 lbs. (baggage).
Remove aircraft emergency egress window (e.g., 50 lb.) or open aircraft door(s).
2. Push/Pull
Without assistance, pull/drag uncooperative individuals (e.g., subject) 5-150 feet during an arrest situation.
Without assistance, physically restrain or subdue a resistive individual (e.g., subject, mentally ill individual, drugged person) using reasonable force.
Defend oneself against attack and protect weapon from a seated position. (e.g., grappling punching/kicking).
Without assistance, use bodily force (e.g., body, foot) to gain entry through a locked door (e.g., lavatory door).
3. Climb
Climb over seats, galley carts, or passengers lying down in the aisle during emergency or close combat situations.
4. Quick Movements
Quickly get out of aircraft seat in response to an emergency or to pursue subject.
Block and evade blows, punches, kicks, etc., with arms, hands or legs.
Perform counter measures to disarm subject with gun.
5. Bends/Stoop/Reach
Stoop/Squat to inspect or search for objects or evidence under aircraft seats, in lavatory, and in galley.
Reach overhead to open and search overhead bins.
6. Stand
Stand for one hour or more.
7. Run
Run in aircraft in pursuit of subject or to quickly respond to an incident scene.
Physically restrain a subject after running.
8. Sit
Sit for one hour or more in an aircraft.
9. Firearms
Load and unload assigned handgun.
10. Operate Hand Controls
Operate flight deck controls and/or instrumentation to stabilize an aircraft in flight.

WARNING: This document may contain Privacy Act protected or other sensitive information and should be protected from unauthorized disclosure. TSA employees and contractors may share this information within DHS on a need-to-know basis. Disclosure outside of DHS must be approved by the Office of Chief Counsel or TSA Privacy Office.

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: TSA is collecting this information about you to determine your suitability to serve as a Federal Air Marshal. This is a voluntary collection of information; however, failure to furnish the requested information may result in an inability to consider you for a position as a Federal Air Marshal. TSA estimates that the total average burden per response associated with this collection is approximately one hour (or 15 minutes if not submitting an explanation). 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 1652-0043, which expires 07/31/2019. Send comments regarding this burden estimate or collection to: TSA-11, Attention: PRA 1652-0043, Law Enforcement/Federal Air Marshal Service Physical Mental Health Certification, 601 South 12th Street, Arlington, VA 20598-6011.

Section I. Healthcare Provider's Evaluation (cont'd)
Essential Job Tasks and Performance Requirements			Yes	No	N/A
11. Write
Complete reports consisting of short descriptive phrases and/or fills in the blanks.
Complete narrative reports.
12. Read
Read reports consisting of short, descriptive phrases.
Read operations orders and intelligence briefings to determine mission specific requirements.
Read information displayed on computer screens.
13. Comprehension/Cognitive Skills
Survey incident scene and quickly gather information to immediately determine appropriate course of action (e.g., intervene, draw weapon).
Identify individuals known to pose, or suspected of posing a risk of terrorism or a threat to airline or passenger safety.
Determine whether a situation requires verbal de-escalation or use of force.
Make an instantaneous decision whether to use physical or deadly force in aircraft or ground situations.
Prioritize the required actions at an incident.
Adapt and adjust plans in response to changes in circumstances during an incident, arrest, or seizure of evidence.
Maintain appropriate confidentiality of non-public information about people investigations, etc.
Detect smells that should be investigated and approximate their origin (e.g., narcotics, smoke, gas, alcohol).
Assist in emergency evacuations from aircraft.
14. Calculate/Communicate
Perform simple arithmetic calculations.
Issue quick, clear and forceful directions to subjects and passengers in an emergency or other situation.
Diffuse arguments (e.g., domestic, other arguments) by using verbal de-escalation techniques.
Communicate description of individuals, explosive devices, or incidents under stressful conditions.
15. Training
Fire 200-500 rounds with assigned firearm at target during practice from standing, kneeling, squatting, prone, moving and behind barricade positions.
Practice close quarter countermeasure weapons skills in simulated aircraft during training.
Participate in physical fitness training such as running, weight training, elliptical trainer, push ups, and other aerobic and training exercise.
Practice defensive tactics maneuvers. (e.g., grappling, striking and restraint techniques).
Maintain proficiency in use of required safety equipment on aircraft (e.g., fire extinguisher, seat extraction tool, oxygen bottle).
16. Flight
Tolerate pressure changes related to multiple, daily ascents/descents in a commercial aircraft.
Section II. Signatures
It is my medical opinion that [Enter patient's name here] is limited by the physical restrictions identified in the "NO" column.
Anticipated length of restriction:
Healthcare Provider's Printed Name:	Healthcare Provider's Specialty:
Healthcare Provider's Signature:		Date of Signature:
Office Address:		Office Phone Number:

WARNING: This document may contain Privacy Act protected or other sensitive information and should be protected from unauthorized disclosure. TSA employees and contractors may share this information within DHS on a need-to-know basis. Disclosure outside of DHS must be approved by the Office of Chief Counsel or TSA Privacy Office.

PAPERWORK REDUCTION ACT STATEMENT OF PUBLIC BURDEN: TSA is collecting this information about you to determine your suitability to serve as a Federal Air Marshal. This is a voluntary collection of information; however, failure to furnish the requested information may result in an inability to consider you for a position as a Federal Air Marshal. TSA estimates that the total average burden per response associated with this collection is approximately one hour (or 15 minutes if not submitting an explanation). If you have any comments regarding this form, you can write to TSA, Office of Law Enforcement/Federal Air Marshal Service, 601 S. 12th Street, Arlington, VA 22202. 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 1652-0043, which expires 07/31/2019.

Previous editions of this form are obsolete.

TSA Form 1133-3 (2/19) rev. [File: 1100.7.2]

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