Treating Physician Status Report

Law Enforcement/Federal Air Marshal Service (OLE/FAMS) Physical and Mental Health Certification

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1652-0043 can be found here:

Documents and Forms

Document Name Document Type
Form TSA Form 1163 Treating Physician Status Report Form and Instruction
TSA Form 1163 Treating Physician Status Report TSA Form 1163, Treating Physician Status Report 6.26.2019.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Treating Physician Status Report	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	TSA Form 1163	Treating Physician Status Report	TSA Form 1163, Treating Physician Status Report 6.26.2019.docx		Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: Employee Medical File of Records of TSO	FR Citation: 71 FR 35360

Number of Respondents: 600	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	600	600
Annual IC Time Burden (Hours)	150	150
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.