Change Justification for NOAA Health Services Questionnaire

CHANGE JUSTIFICATION FOR
NOAA HEALTH SERVICES QUESTIONNAIRE
OMB CONTROL NO. 0648-0283, NOAA’S TEACHER AT SEA PROGRAM
NOAA’s Teacher at Sea program requires completion of the health services questionnaire for
teachers applying for this program (as well as scientists, other staff and other volunteers sailing
on our research vessels). This revised version of the web-based questionnaire contains only the
pertinent medical information for determining fitness to sail, with the minimum of personally
identifiable information (PII).
The following questions will no longer be on the form:
SSN, birthdate (year of birth only is now asked), sex, citizenship, passport number, next of kin,
relationship and address, medical insurance company and policy number.
Medical and lifestyle questions no longer asked: general state of health (excellent, good, fair,
poor), month/year of most recent physical exam and chest x-ray, dietary restrictions coughed up
blood, paralysis, sedentary lifestyle, family history of heart attack before age 45, high cholesterol
, tobacco use; immunizations: hepatitis A series, dose 1 and 2 , hepatitis B series, dose 1, 2, and
3, cholera, diphtheria, influenza (most recent), immunoglobulin (IG), malaria, polio, measles,
mumps, rubella (MMR), typhoid fever, yellow fever.
This statement is no longer on the form: "I authorize any of the doctors, hospitals, or clinics
mentioned above to furnish the Government a complete transcript of my medical record for
purposes of processing my application for this employment or service.
The revised form is highlighted to show the few new questions, e.g. additional detail on one
vaccination and revised contact information questions. Also, a short section has been added to
include questions related to functional abilities for residing aboard a ship at sea.
The revised form may take slightly less time to complete, but at this time we are not requesting a
change in burden.
Note: a Privacy Act System of Records Notice is under review at the Department of Commerce.