NSF 1461 Privacy Notice and Paperwork Reduction Act Statement

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230
PRIVACY NOTICE and PAPERWORK REDUCTION ACT STATEMENT
Medical Examination Records for Service in Polar Regions

The National Science Foundation’s Office of Polar Programs is responsible for ensuring that all personnel
traveling to the polar regions under the auspices of the United States meet certain medical standards. This
medical screening process requires that certain medical records be generated on each individual
participating in the program.
The information requested on NSF provided forms is solicited under the authority of the National Science
Foundation Act of 1950, as amended, 42 U.S.C. 1870 et seq. It will be used by NSF and its contractors
and subcontractors in the medical screening process to determine whether an applicant is qualified for
deployment to the polar regions. An individual medical file will include information collected to
determine whether one is qualified for assignment to the polar regions, as well as clinical files that may be
generated if one receives medical treatment in any of the US sponsored medical clinics in Antarctica or in
the Arctic, as well as any off-ice treatment facilities arranged by the NSF or its contractor or
subcontractor.
The records are used for three primary purposes: (1) to determine the individual’s fitness for assignment
in the polar regions, including individual waiver requests; (2) to assist in determining an appropriate
course of medical/dental treatment should the individual seek medical care with any medical care
provider while deployed; and (3) to provide documentation for addressing quality of care issues
associated with these medical functions.
Records contained within this system may be released to individuals involved in those three functions.
Such individuals include, in addition to designated NSF employees as needed for assigned duties: (a)
designated medical care practitioners and their administrative support personnel including designated
contractors and subcontractors involved in determining an individual’s fitness for Antarctic or Arctic
assignment, including individual waiver requests; (b) medical care providers during deployment including
those in NSF-supported stations and field camps in the polar regions where the individual is assigned; and
(c) medical experts advising the NSF on quality of medical care issues associated with NSF’s polar
research programs. In addition to these purposes, information in the medical records may be released to
the individual’s personal or examining physician or the individual’s designated emergency point of
contact when disclosure is necessary to determine initial medical clearance or to review treatment options
if the individual requires medical attention while on assignment in the polar regions. The determination
of whether the individual is physically qualified/not physically qualified (PQ/NPQ) may be released to
representatives of the individual’s sponsoring organization including academic institutions, and
investigators on a grant to inform them whether an individual is approved for deployment or not.
If necessary, information may be released to Federal, state, or local agencies, or foreign governments
when disclosure is necessary to obtain records in connection with an investigation by or for the NSF; and
to another Federal agency, a court, or a party in litigation before a court or in an administrative
proceeding if the government is a party, or when NSF determines that the litigation or anticipated
litigation or proceeding is likely to affect the Agency.

NSF Form 1461 Page 1 of 3 (JAN 2011)
OMB CONTROL NUMBER 3145-0177: Expires

Original: Contractor Medical Staff

Applicant: Please retain a copy for your records

Submission of the information requested is voluntary. However, if you fail to provide any of the
requested information, NSF or its contractor may be unable to process or to approve your application for
polar deployment.
More detail about how and where these records are maintained in accordance with the Privacy Act, 5
U.S.C. 552a, is contained in the National Science Foundation’s System of Records Notice, Medical
Examination Records for Service in the Polar Regions, available upon request from the NSF 1 . No
disclosure of information contained in your medical file will be made except as described by the NSF’s
System Notice or as otherwise authorized by law. You may request a copy of your records for review.
PAPERWORK REDUCTION ACT STATEMENT
Public reporting burden for this information collection is estimated to be at least 12.3 hours per
participant per packet of forms with the exception of Official Visitors, whose burden is approximately 7.6
hours. All individuals, except the uniformed services of the Department of Defense, deploying to the
Antarctic to Greenland and to other select areas of the Arctic that are under the auspices of the National
Science Foundation’s Office of Polar Programs must complete these forms. Send comments regarding
this burden estimate and any other aspect of this collection of information, including suggestions for
reducing this burden, to: Reports Clearance Officer, National Science Foundation, Division of
Administrative Services, Room 295, 4201 Wilson Boulevard, Arlington, VA 22230.
An agency may not conduct or sponsor, and a person is not required to respond to an information
collection unless it displays a valid OMB control number. The OMB number for this project is 31450177.

1

For a copy of the System Notice, please contact the OPP Safety and Health Officer at NSF at (703) 306-1032, or
write to Safety and Health Officer, Office of Polar Programs, National Science Foundation, 4201 Wilson Blvd.,
Suite 755, Arlington, VA 22230.

NSF Form 1461 Page 2 of 3 (JAN 2011)
OMB CONTROL NUMBER 3145-0177: Expires

Original: Contractor Medical Staff

Applicant: Please retain a copy for your records

NATIONAL SCIENCE FOUNDATION
4201 WILSON BOULEVARD
ARLINGTON, VIRGINIA 22230

OFFICE OF POLAR PROGRAMS

Medical Risks for NSF-Sponsored Personnel Traveling to the Polar Regions
Travel to the polar regions imparts certain risks to the traveler, because of harsh environmental conditions encountered,
limitations in the medical care available, and difficulties, in emergencies, of providing timely evacuation to tertiary medical
care facilities in the U.S. or other countries in the polar regions. United States polar programs participants should consider
these risks before deciding to deploy to the polar regions.
Greenland, the world’s largest island, is located in the Arctic region and is characterized by an extreme climate. Whenever
you are in an arctic area you can expect changeable weather and must be prepared for all kinds of weather. The Polar Circle
crosses the country south of Sisimiut/Holsteinsborg. Therefore, a great part of Greenland has dark winters and the midnight
sun in the summertime. The temperatures vary between minus 5 degrees Celsius to minus 30 degrees Celsius in the winter
and plus 5 degrees Celsius to plus 15 degrees Celsius in the summer. Generally the climate is Arctic, the main temperature
being zero to subzero. The maximum temperature in the warmest month is 12 degrees Celsius. The coldest months are
February and March. However, the temperatures do not feel as cold as in Europe as the wind is very dry. Greenland can only
be reached by airplane.
It is important that polar participants recognize these limitations in medical care while they are deployed. It is, in part,
because of these limitations, that the NSF requires medical and dental screening of personnel prior to deployment to the polar
regions. These medical screening examinations are necessary to determine the presence of medical conditions that could
threaten the health or safety of the individual while deployed. Persons who fail to meet these medical/dental screening criteria
will be notified of the specific reason(s) for their disqualification. Disqualified individuals may request reconsideration by
completing a waiver request package (obtained from the designated NSF support contractor).
Pre-deployment screening can identify existing medical conditions that may be difficult or impossible to treat effectively in
the polar regions. Participants should realize that serious accidents or injuries might challenge the medical care system, as
well. Therefore, individuals should recognize the limitations in the medical care system before they engage in any risk-taking
behaviors (whether on-the-job or during recreational pursuits) that may result in accidents or injuries.
Data collected as a result of this medical screening requirement are maintained in accordance with the Privacy Act (5 USC
552a) of 1974 and protected against unauthorized release, as described in the appended Privacy Notice.
I have read and understand this information sheet.

________________________________
Print Name

NSF Form 1461 Page 3 of 3 (JAN 2011)
OMB CONTROL NUMBER 3145-0177: Expires

__________________________________
Signature and Date

Original: Contractor Medical Staff

Applicant: Please retain a copy for your records