Form 1458 Personal Information Form

PERSONAL INFORMATION
NAME (Last, First, Middle)

SEX
M

F

TELEPHONE NUMBERS
(include area code)
RESIDENCE: ____________

PERMANENT ADDRESS (Street, City, State, Zip Code, Country)

WORK: ________________
PARENT ORGANIZATION
NSF
OFFICIAL VISITOR EVENT NUMBER__________

RPSC-FULL-TIME

RPSC-CONTRACTOR

SCIENCE GROUP MEMBER EVENT NUMBER__________

TECHNICAL EVENT NUMBER___________

Principal Investigator___________________________________

Company Name___________________________

OTHER___________________________________ JOB TITLE_________________________________
(All participants complete for appropriate gear)
DATE OF BIRTH (month, day, year)
PLACE OF BIRTH (city, state, country)

U. S. CITIZEN
NATIONALITY (if not a U.S. Citizen)
YES
NO
NAME OF PERSON TO BE NOTIFIED IN CASE OF ACCIDENT/DEATH

ADDRESS

RELATIONSHIP

TELEPHONE NUMBER(S)

TRAVEL INFORMATION
U.S. Departure Date (Estimated) ________________
Dates in Antarctica (Estimated) FROM: ___________________ TO: ________________________
SEASON:

WINFLY (August deployment)

SUMMER (Sep thru Feb)

CLOTHING INFORMATION
HEIGHT: ___________ WEIGHT: ___________
COAT SIZE: ___________ CHEST SIZE: ___________
SHIRT SIZE (check one):
SMALL

MEDIUM

WAIST: __________

LARGE

EXTRA-LARGE

HIP: _________ (women)

INSEAM: ___________ (men) SHOE SIZE: ___________

WINTER (March thru August)
WORK SITE INFORMATION

Check all that apply. For multiple sites, note dates next to site.
CONTINENTAL SYSTEM
MCMURDO STATION
DRY VALLEYS
SOUTH POLE
OTHER_______________________________
PENINSULA SYSTEM
PALMER STATION
R/V NATHANIEL B. PALMER
R/V L.M. GOULD
OTHER (describe) ________________________

________________________________________
HAT SIZE: ___________

GLOVE SIZE: ____________

Have you previously deployed to Antarctica?

Yes

No

Additional Requirements:
Most recent year: __________________
NSF Form 1458 Page 1 of 2 (FEB 2005)
OMB CONTROL NUMBER 3145-0177 Expires SEP 2010

Original: NSF Contractor

NATIONAL SCIENCE FOUNDATION

4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230
PRIVACY NOTICE

PERSONAL INFORMATION FOR DEPLOYMENT TO AND FROM ANTARCTICA

The National Science Foundation’s Office of Polar Programs provides transport and logistical support for
individuals traveling to and working in Antarctica under the auspices of the United States Antarctic Program
(USAP). The NSF and its contractors and subcontractors will use the information collected on this form to
facilitate deployment or redeployment of individuals participating in the USAP.
The information requested is solicited under the authority of the National Science Foundation Act of 1950, as
amended, 42 U.S.C. 1870; 16 U.S.C. § 3101. It may be disclosed to Office of Polar Programs civilian
contractors and their subcontractors in connection with their responsibilities for coordinating the administrative
processing and tracking of persons deploying to Antarctica. These responsibilities include proper outfitting for
deployment, facilitating medical clearances, coordinating cargo handling and tracking, and maintaining
emergency contacts. It may also be disclosed to: Air National Guard medical personnel to track medical
clearances; family members, or other persons designated by the deploying or deployed individual, in instances
of emergency; other Federal agencies providing transport, search and rescue, and other logistical assistance to
and from Antarctica, including manifest information for pilots or crew transporting individuals to and from
Antarctica; other Federal agencies and academic or other organizations when the records are relevant to an
agency decision with regard to disciplinary or other administrative actions concerning an employee; another
Federal agency, a court, or a party, or when NSF determines that the litigation or anticipated litigation or
proceeding is likely to affect the Agency; Federal, state, or local agencies, or foreign governments, when
disclosure is necessary to obtain records in connection with an investigation by or for the NSF; and
representatives of the New Zealand government or other foreign governments when deployment involves travel
through, or use of, New Zealand or other foreign government facilities, and the information is necessary to
ensure safe and efficient deployment, including compliance with immigration requirements.
Submission of the information requested is voluntary. However, if you fail to provide any of the requested
information, NSF or its contractor may be unable to process or to approve your application for deployment
through the USAP.
Public reporting burden for this collection of information is estimated to average less than one-quarter hour per
response. Send comments regarding this burden estimate and any other aspect of this collection of information,
including suggestions for reducing this burden to: Ms. Suzanne Plimpton, Reports Clearance Officer, Division
of Administrative Services, National Science Foundation, Arlington, VA 22230.

NSF Form 1458 Page 2 of 2 (FEB 2005)
OMB CONTROL NUMBER 3145-0177 Expires SEP 2010