Information Collection

Mental Health Certification

IC 46519 under ICR 202305-1652-002 · OMB 1652-0043.

Documents and Forms

Document Name Document Type
Form TSA Form 1164 Mental Health Certification Form and Instruction
TSA Form 1164 Mental Health Certification TSA Form 1164, Mental Health Certification.pdf Form and Instruction
TSA Form 1164 Mental Health Certification TSA Form 1164, Mental Health Certification.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	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 and Instruction	TSA Form 1164	Mental Health Certification	TSA Form 1164, Mental Health Certification.pdf		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: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	-500	600
Annual IC Time Burden (Hours)	100	-500	600
Annual IC Cost Burden (Dollars)	0	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.