Medical Clearance Process for Deployment to the Polar Regions

Forms and Documents

Document Name	Status
Form NSF-1700 Medical Clearance Process for Deployment to the Polar Regions Form and Instruction	New
Form 1461 NSF 1461, Privacy Notice, Antarctica Form and Instruction	Removed
Form 1458 NSF 1458, Personal Information Form Form and Instruction	Removed
Form 1457 NSF 1457, Important Notice for Participants in the United States Antarctic Program Form and Instruction	Removed
Form 1429-I NSF 1429-I, Individual Statement of Sujpport Form and Instruction	Removed
Form 1429-B NSF 1429-B, Employer Statement of Support for Waiver Request-Arctic Form and Instruction	Removed
Form 1429-A NSF 1429-A, Employer Statement of Support for Waiver Request-Antarctic Form and Instruction	Removed
Form 1428-B NSF 1428-B, Request for Waiver of NSF/OPP Medical Requirements-Arctic Form and Instruction	Removed
Form 1428-A NSF 1428-A, Request for Waiver of NSF/OPP Medical Requirements-Antarctica Form and Instruction	Removed
Form 1425-B NSF 1425-B, Polar Dental Examination - Arctic Form and Instruction	Removed
Form 1423-C NSF 1423-C, Polar Physical Examination Form and Instruction	Removed
Form 1423-B NSF 1423-B, Polar Physical Examination Form and Instruction	Removed
Form 1421 NSF 1421-B, Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions - Arctic Form and Instruction	Removed
Form 1427 NSF 1427, Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years Form and Instruction	Removed
Form 1425-A NSF 1425-A, Polar Dental Examination - Antarctica Form and Instruction	Removed
Form 1424 NSF 1424, Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test Form and Instruction	Removed
Form 1423 NSF 1423-A, Polar Physical Examination - Antarctica Form and Instruction	Removed
Form 1422 NSF 1422, Polar Physical Examination - Medical History - Antarctica Form and Instruction	Removed
Form 1421-A NSF 1421-A, Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica Form and Instruction	Removed
31450177 Supporting Statement 2014.docx Supporting Statement A	2014-04-28
Presidential Memo 6646.pdf Supplementary Document	2014-04-28
42 USC 1870.pdf Supplementary Document	2014-04-28
45cfr675.pdf Supplementary Document	2007-09-19
privacy act.pdf Supplementary Document	2007-09-19

IC Document Collections

IC ID	Document Title	Status
211404	Medical Clearance Process for Deployment to the Polar Regions Form and Instruction	New
182110	Privacy Notice - Arctic Other-Privacy Notice for Potential Participants	Removed
182109	Privacy Notice, Antarctica Other-Privacy Notice for Potential Participants	Removed
182107	NSF 1461, Privacy Notice, Antarctica Form and Instruction	Removed
182105	NSF 1458, Personal Information Form Form and Instruction	Removed
182104	NSF 1457, Important Notice for Participants in the United States Antarctic Program Form and Instruction	Removed
182103	NSF 1429-I, Individual Statement of Sujpport Form and Instruction	Removed
182102	NSF 1429-B, Employer Statement of Support for Waiver Request-Arctic Form and Instruction	Removed
182101	NSF 1429-A, Employer Statement of Support for Waiver Request-Antarctic Form and Instruction	Removed
182100	NSF 1428-B, Request for Waiver of NSF/OPP Medical Requirements-Arctic Form and Instruction	Removed
182099	NSF 1428-A, Request for Waiver of NSF/OPP Medical Requirements-Antarctica Form and Instruction	Removed
182098	NSF 1425-B, Polar Dental Examination - Arctic Form and Instruction	Removed
182097	NSF 1423-C, Polar Physical Examination Form and Instruction	Removed
182096	NSF 1423-B, Polar Physical Examination Form and Instruction	Removed
182095	NSF 1421-B, Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions - Arctic Form and Instruction	Removed
182055	NSF 1427, Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years Form and Instruction	Removed
182054	NSF 1425-A, Polar Dental Examination - Antarctica Form and Instruction	Removed
182052	NSF 1424, Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test Form and Instruction	Removed
182050	NSF 1423-A, Polar Physical Examination - Antarctica Form and Instruction	Removed
182045	NSF 1422, Polar Physical Examination - Medical History - Antarctica Form and Instruction	Removed
182043	NSF 1421-A, Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica Form and Instruction	Removed

ICR Details

OMB Control No: 3145-0177	ICR Reference No: 201404-3145-001
Status: Historical Active	Previous ICR Reference No: 201101-3145-003
Agency/Subagency: NSF	Agency Tracking No:
Title: Medical Clearance Process for Deployment to the Polar Regions
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/19/2014
	Date Received in OIRA: 04/28/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2017	36 Months From Approved	06/30/2014
Responses	3,300	0	27,965
Time Burden (Hours)	33,600	0	34,907
Cost Burden (Dollars)	1,075,008	0	0

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Abstract: The National Science Foundation requires all U.S. Antarctic participants and all participants deploying to Greenland and other select regions of the Arctic to take and pass a physical examination prior to deployment. NSF uses the information to determine the medical and dental health and psychological suitability of the polar participants; to determine whether accommodations exist to treat certain ailments and to provide on-site treatment, when needed, without doing harm. The respondents are all USAP participants; all Greenland participants in select regions of the Arctic that are under the auspices of USAP.

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Authorizing Statute(s): US Code: 42 USC 1870 Name of Law: General Authority of Foundation
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 68479	11/14/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 23013	04/25/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
NSF 1423-A, Polar Physical Examination - Antarctica	1423	Polar Physical Exam
Medical Clearance Process for Deployment to the Polar Regions	NSF-1700	Medical Clearance Process for Deployment to the Polar Regions
NSF 1422, Polar Physical Examination - Medical History - Antarctica	1422	Polar Phsyical Examination - Medical History
NSF 1421-A, Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica	1421-A	Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica
NSF 1424, Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test	1424	Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test
NSF 1425-A, Polar Dental Examination - Antarctica	1425-A	Polar Dental Examination
NSF 1427, Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years	1427	Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years
NSF 1421-B, Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions - Arctic	1421	Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions
NSF 1423-B, Polar Physical Examination	1423-B	Polar Physical Exam
NSF 1423-C, Polar Physical Examination	1423-C	Polar Physical Exam
NSF 1425-B, Polar Dental Examination - Arctic	1425-B	Polar Dental Examination - Arctic
NSF 1428-A, Request for Waiver of NSF/OPP Medical Requirements-Antarctica	1428-A	Request for Waiver of NSF/OPP Medical Requirements - Antarctica
NSF 1428-B, Request for Waiver of NSF/OPP Medical Requirements-Arctic	1428-B	Request for Waiver of NSF/OPP Medical Requirements-Arctic
NSF 1429-A, Employer Statement of Support for Waiver Request-Antarctic	1429-A	Employer Statement of Support for Waiver Request
NSF 1429-B, Employer Statement of Support for Waiver Request-Arctic	1429-B	Employer Statement of Support for Waiver Request-Arctic
NSF 1429-I, Individual Statement of Sujpport	1429-I	Individual Statement of Support
NSF 1457, Important Notice for Participants in the United States Antarctic Program	1457	Important Notice for Participants in the United States Antarctic Program
NSF 1458, Personal Information Form	1458	Personal Information Form
NSF 1461, Privacy Notice, Antarctica	1461, NSF 1461	Privacy Notice - Antarctica ,   Privacy Notice and Paperwork Reduction Act Statement
Privacy Notice, Antarctica
Privacy Notice - Arctic

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,300	27,965	0	-24,665	0	0
Annual Time Burden (Hours)	33,600	34,907	0	-1,307	0	0
Annual Cost Burden (Dollars)	1,075,008	0	0	1,075,008	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The program has streamlined the format of the Polar Programs medical process, combining 15+ separate forms into one continuous packet, eliminating duplication and including a pre-filled format.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 04/28/2014

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