Form TSA Form 3417 TSA Form 3417 CMSDT Program Attendance Roster

DEPARTMENT OF HOMELAND SECURITY

OMB Control No.1652-0028
Expires: 11/30/2024
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Transportation Security Administration
CMSDT PROGRAM ATTENDANCE ROSTER

INSTRUCTIONS: The Crew Member Self Defense (CMSD) Trainer shall complete Section I. w ith the field office location and date of training.
Section II. shall be completed by the trainer or the trainee w ith the trainee name, airline affiliation, airline ID number and contact information.
The CMSD Trainer w ill verify if the training has been completed, if a certification w as received and sign and date Section III.
SECTION I. Training Inform ation
Field Office Location

Date of Training

SECTION II. Roster Inform ation
TO BE COMPLETED
BY TRAINER

TO BE COMPLETED BY TRAINER OR TRAINEE
Name

Airline
Affiliation

Airline
ID Number

Contact Information
(Mailing Address/Email/Phone Number)

Training
Complete

Certification
Received
Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

SECTION III. Signatures
Instructor Signature

Date

PRIVACY ACT STATEMENT: AUTHORITY: 49 U.S.C. § 114(f). PRINCIPAL PURPOSE(S): The information will be used to verify attendance at the Crew
Member Self Defense Training Program, whether or not the training was completed and if a certification wasreceived. ROUTINE USE(S): Thisinformation 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. DISCLO S URE :
Voluntary; failure to furnish the requested information may result in an inability to verify your attendance at the Crew Member Self Defen se T ra in in g P ro g ra m,
whether or not the training was completed and if a certification was received.
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 mi nu t es. A n a g e n c y
may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displaysa currently valid OMB control n u mb e r. T he
OMB control number assigned to this collection is 1652-0028, which expires 11/30/2024. Send comments regarding this burden estimate or any other a sp e ct o f
this collection of information including suggestions for reducing this burden to TSA PRA Officer, 6595 Springfield Center Drive, S p ri ng f iel d, V A 2 0 59 8 -60 1 1.
ATTN: PRA 1652-0028, TSA-11.

Previous editionsof this form are obsolete.
TSA Form 3417 (11/21) rev. [File: 3500.13]

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