Form 1428-B Request for Waiver of NSF/OPP Medical Requirements-Arcti

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230
OFFICE OF POLAR PROGRAMS
703-292-8031

FROM:

_______________________________________(Applicant’s name)

TO:

Head, Polar Environment, Health and Safety Office
Office of Polar Programs, National Science Foundation

VIA:

(Employer)

SUBJECT: Request for Waiver of Arctic Medical Requirements
1. I have been informed of the qualifications for assignment or travel to an Arctic
research or support station, as established in the Office of Polar Programs
Medical Screening Guidelines.
2. I am aware that the physical qualifications criteria are established to: identify
civilian employees, visitors and military personnel working in support of the arctic
program who are physically qualified and temperamentally adapted for
assignment or travel to select regions of the Arctic, and to disqualify those
individuals who may require repeated, prolonged or specialized treatment, whose
presence in the Arctic may endanger his/her own life or safety, and/or the lives or
safety of other personnel. I understand that the criteria established by the Office
of Polar Programs apply equally to all U.S. or foreign visitors to the Arctic who
are sponsored by the National Science Foundation.
3. I am aware that medical facilities and capabilities in the Arctic are limited and
may be quite distant from working or research sites. I understand that the nature
of the polar environment, with its potential hazards and extreme remoteness from
major medical facilities, makes stringent medical histories and physical
examination screening mandatory to ensure freedom from any disability which
might imperil health, restrict activity, or create a burden for one’s associates in
the Arctic.
4. I have been informed that:
a. I have a condition which disqualifies me for assignment/travel to the Arctic.
b. This disqualifying condition is: ___________________________________
______________________________________________________________

NSF Form 1428-B Page 1 of 2
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

(APR 2002)

Request for Waiver of Arctic Medical Requirements

c. This condition is subject to waiver consistent with Arctic Program Medical
Standards and National Science Foundation policy.
5. Knowing and understanding the above, I request the National Science
Foundation to waive the requirements of the Arctic Medical Standards with regard to
the above described disqualification to enable me to travel/be assigned to the Arctic.
I agree to accept and comply with any and all conditions that may be imposed upon
any waiver issued as a result of this request. For and in consideration of receiving
such waiver, and for and on behalf of myself, my personal representatives, heirs and
assigns, I release and discharge the U.S., its agents, servants, or employees,
including but not limited to the National Science Foundation, the Department of
Defense and its agencies, their agents, servants, or employees, whether military or
civilian, and where applicable, VECO, its agents, servants and employees from any
and all claims for property damage, personal injury, or death resulting directly or
indirectly from issuance of this waiver of the above described disqualifying condition.
I, ______________________, do hereby certify on this ______ day of ___________
20____ that I am the individual about whom this Request for Waiver of Arctic
Medical requirements and release of harm pertains. I fully understand this
document and agree to its terms.
In the CITY or COUNTY OF: _______________________________________
STATE OF: __________________ on this _____ day of _____________ 20____
____________________________, who is known to me to be the person named
herein and who did appear before me and signed the foregoing Request for Waiver
and acknowledged to me that he/she voluntarily executed the same.

__________________________
NOTARY PUBLIC (signature)

____________
(date)

My Commission expires ______________________________
(Signature)

NSF Form 1428-B Page 2 of 2
OMB CONTROL NUMBER 3145-0177: Expires SEP 2010

(APR 2002)