Information Collection

NSF 1422, Polar Physical Examination - Medical History - Antarctica

IC 182045 under ICR 200708-3145-001 · OMB 3145-0177.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3145-0177 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1422 NSF 1422, Polar Physical Examination - Medical History - Antarctica	Form and Instruction
1422 Polar Physical Examination � Medical History 1422 - Med History for Polar Programs.pdf	Form and Instruction

IC Title:

NSF 1422, Polar Physical Examination - Medical History - Antarctica

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 45 CFR 675

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1422	Polar Physical Examination ï¿½ Medical History	1422 - Med History for Polar Programs.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: NSF-19, Medical Examination Records for Service in the Polar Regsion

FR Citation: 62 FR 59895

Number of Respondents: 3,600

Number of Respondents for Small Entity: 0

Affected Public: Federal Government

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	3,600	3,600
Annual IC Time Burden (Hours)	3,600	3,600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.