Medical Clearance Process for Deployment to the Polar Regions

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1461 Privacy Notice - Antarctica	Form and Instruction	New	Available
Form 1458 Personal Information Form	Form and Instruction	New	Available
Form 1457 Important Notice for Participants in the United States Antarctic Program	Form and Instruction	New	Available
Form 1429-I Individual Statement of Support	Form and Instruction	New	Available
Form 1429-B Employer Statement of Support for Waiver Request-Arctic	Form and Instruction	New	Available
Form 1429-A Employer Statement of Support for Waiver Request	Form and Instruction	New	Available
Form 1428-B Request for Waiver of NSF/OPP Medical Requirements-Arctic	Form and Instruction	New	Available
Form 1428-A Request for Waiver of NSF/OPP Medical Requirements - Antarctica	Form and Instruction	New	Available
Form 1425-B Polar Dental Examination - Arctic	Form and Instruction	New	Available
Form 1423-C Polar Physical Exam	Form and Instruction	New	Available
Form 1423-B Polar Physical Exam	Form and Instruction	New	Available
Form 1421 Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions	Form and Instruction	New	Available
Form 1427 Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years	Form and Instruction	New	Available
Form 1425-A Polar Dental Examination	Form and Instruction	New	Available
Form 1424 Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test	Form and Instruction	New	Available
Form 1423-A Polar Physical Examination	Form and Instruction	New	Available
Form 1422 Polar Physical Examination � Medical History	Form and Instruction	New	Available
Form 1421-A Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica	Form and Instruction	New	Repair queued
31450177 Supporting Statement.doc	Supporting Statement A	Uploaded 2007-09-24	Available
45cfr675.pdf	Supplementary Document	Uploaded 2007-09-19	Available
privacy act.pdf	Supplementary Document	Uploaded 2007-09-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33057	Medical Clearance Process for Deployment to the Polar Regions		Removed
182110	Privacy Notice - Arctic	Other-Privacy Notice for Potential Participants	New
182109	Privacy Notice, Antarctica	Other-Privacy Notice for Potential Participants	New
182107	NSF 1461, Privacy Notice, Antarctica	Form and Instruction	New	Privacy Notice - Antarctica
182105	NSF 1458, Personal Information Form	Form and Instruction	New	Personal Information Form
182104	NSF 1457, Important Notice for Participants in the United States Antarctic Program	Form and Instruction	New	Important Notice for Participants in the United States Antarctic Program
182103	NSF 1429-I, Individual Statement of Sujpport	Form and Instruction	New	Individual Statement of Support
182102	NSF 1429-B, Employer Statement of Support for Waiver Request-Arctic	Form and Instruction	New	Employer Statement of Support for Waiver Request-Arctic
182101	NSF 1429-A, Employer Statement of Support for Waiver Request-Antarctic	Form and Instruction	New	Employer Statement of Support for Waiver Request
182100	NSF 1428-B, Request for Waiver of NSF/OPP Medical Requirements-Arctic	Form and Instruction	New	Request for Waiver of NSF/OPP Medical Requirements-Arctic
182099	NSF 1428-A, Request for Waiver of NSF/OPP Medical Requirements-Antarctica	Form and Instruction	New	Request for Waiver of NSF/OPP Medical Requirements - Antarctica
182098	NSF 1425-B, Polar Dental Examination - Arctic	Form and Instruction	New	Polar Dental Examination - Arctic
182097	NSF 1423-C, Polar Physical Examination	Form and Instruction	New	Polar Physical Exam
182096	NSF 1423-B, Polar Physical Examination	Form and Instruction	New	Polar Physical Exam
182095	NSF 1421-B, Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions - Arctic	Form and Instruction	New	Medical Risks for NSF- Sponsored Personnel Traveling to the Polar Regions
182055	NSF 1427, Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years	Form and Instruction	New	Authorization for Treatment of Field-Team Member/Participant Under the Age of 18 Years
182054	NSF 1425-A, Polar Dental Examination - Antarctica	Form and Instruction	New	Polar Dental Examination
182052	NSF 1424, Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test	Form and Instruction	New	Medical Screening for Blood-Borne Pathogens/Consent for HIV Antibody Blood Test
182050	NSF 1423-A, Polar Physical Examination - Antarctica	Form and Instruction	New	Polar Physical Examination
182045	NSF 1422, Polar Physical Examination - Medical History - Antarctica	Form and Instruction	New	Polar Physical Examination � Medical History
182043	NSF 1421-A, Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica	Form and Instruction	New	Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica

ICR Details

OMB Control No: 3145-0177	ICR Reference No: 200708-3145-001
Status: Historical Active	Previous ICR Reference No: 200404-3145-001
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: 01/07/2008
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/24/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2011	36 Months From Approved	01/31/2008
Responses	32,165	0	3,120
Time Burden (Hours)	37,179	0	29,617
Cost Burden (Dollars)	0	0	0

---

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. The 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 Greeland participants in select regions of the Arctic that are under the auspices of...

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 29001	05/23/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 54300	09/24/2007
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 20

table that charts list of burden

IC Title	Form No.	Form Name
Medical Clearance Process for Deployment to the Polar Regions	1421-1429, 1451-1456, 1461-1469
NSF 1421-A, Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica	1421-A	Medical Risks for NSF-Sponsored Personnel Traveling to Antarctica
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 1422, Polar Physical Examination - Medical History - Antarctica	1422	Polar Physical Examination � Medical History
NSF 1423-A, Polar Physical Examination - Antarctica	1423-A	Polar Physical Examination
NSF 1423-B, Polar Physical Examination	1423-B	Polar Physical Exam
NSF 1423-C, Polar Physical Examination	1423-C	Polar Physical Exam
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 1425-B, Polar Dental Examination - Arctic	1425-B	Polar Dental Examination - Arctic
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 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	Privacy Notice - Antarctica
Privacy Notice - Arctic
Privacy Notice, Antarctica

---

ICR Summary of Burden

table that charts list 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	32,165	3,120	0	29,045	0	0
Annual Time Burden (Hours)	37,179	29,617	0	7,562	0	0
Annual Cost Burden (Dollars)	0	0	0	0	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 increase in burden is due to increased submissions of potential program participants within the Polar Regions.

---

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]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 09/24/2007

---