Information Collection

FAMS Mental Health Certification

IC 46519 under ICR 201210-1652-002 · OMB 1652-0043.

⚠️ Notice: This information collection may be referencing outdated material.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 1164 FAMS Mental Health Certification Form
TSA 1164 Mental Health Certification MHC_FINAL.doc Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	FAMS Mental Health Certification	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 14 CFR 67

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	TSA 1164	Mental Health Certification	MHC_FINAL.doc		Yes	Yes	Fillable Fileable

Line of Business: Homeland Security

Subfunction: Border and Transportation Security

Privacy Act System of Records
Title: Employee Medical File System Records	FR Citation: 65 FR 24750

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

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	600	-9,400	10,000
Annual IC Time Burden (Hours)	600	-9,400	10,000
Annual IC Cost Burden (Dollars)	270	-4,130	4,400

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.