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TSA Form 1133 1FitnessforDuty - TSO Daily Fitness for Duty

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TSA Form 1133 1FitnessforDuty - TSO Daily Fitness for Duty Powered By Docstoc
					                                                                                                          TSO Daily Fitness for Duty
                                                                                                   Possible Indicators of Impairment
 INSTRUCTIONS: This form is an optional tool in accordance with TSA MD 1100.33-1, TSO Daily Fitness for Duty. Management officials may
 use this form to assist in conducting fitness for duty observations. Suspicion that a TSO is impaired and not fit for duty must be based on
 observation of actions, appearance, or conduct that demonstrates a significant change in appearance and/or behavior. Use Section I as a
 reference during observations. Sections II, III and IV may be used only when an unfit determination is made. If Section I—the checklist—is the
 only portion used, destroy the form at the end of the employee’s tour-of-duty. If an unfit determination is made and Sections II, III and IV are used,
 transfer the form and any attachments to the local Employee Relations Specialist or Field Counsel. Management officials may retain a copy of the
 completed form in the employee’s Employee Performance Folder.

  SECTION I – OBSERVED BEHAVIOR CHECKLIST (check all that apply)
  Part A. Appearance
     Blood shot eyes                             Glassy look                                   Personal grooming                      Relaxed posture
     Body odor of alcohol                        Inability to focus                            Pinpoint pupils                        Trembling hands

     Drowsy/Sleepy                               Light sensitivity                             Poor dexterity                         Untidy clothing

     Face flushed                                Odor of alcohol on breath                     Poor eye-hand coordination             Unusual sweating

     Fumbling                                    Pale                                          Pupils dilated                         Watery eyes
  Part B. Walking/Standing
     Stumbling                                   Swaying movements/Jerky                       Unbalanced (falls)                     Unusually slow movements
  Part C. Speech
     Exaggerated pronunciation                   Muddled speech                                Out of place laughter                  Unusually soft or loud
     Excessively talkative                       Mumbling                                      Rapid

     Incoherent                                  Non-responsive                                Slurred
  Part D. Behavior
     Agitated                  Frequent use of breath sprays/mints               Inattentive                                           Sullen
     Blaming                   Frequent use of eye drops                         Irritable                                             Suspicious

     Depressed                 General malaise                                   Loss of inhibitions (cursing, sexual advances, risk taking)

     Distracted                Hostile                                           Moody

                                              Complete ONLY when an unfit determination is made.
  SECTION II – EMPLOYEE DATA
  Employee Name:                                                                                                                   Airport Code:
  Current Position:
                             Include Title, Occupational Series and Pay Band (e.g., TSO-1802-D, LTSO-1802-G)
  SECTION III – ADDITIONAL INFORMATION (attach pages for additional space)




  SECTION IV – CERTIFICATION



    Management Official’s Printed Name                                 Management Official’s Signature                                          Assessment Date
 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.
TSA Form 1133-1, 10/10 [File: 1100.7.3]

				
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