JSC Form 1830 – Report of Medical Examination

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form JSC Form 1830 JSC Form 1830 – Report of Medical Examination	Form	New	Available
2018-22271 JSC JF1830 30 Day FRN_Vol 83_No 198_101218.pdf	Supplementary Document	Uploaded 2019-02-14	Available
2018-13139 JSC JF1830 60day FRN Vol83_No118_061918.pdf	Supplementary Document	Uploaded 2019-02-14	Available
JSC Neutral Buoyancy Guest Diver Physical Supporting Statement A_120418.docx	Supporting Statement A	Uploaded 2019-02-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
234962	JSC Form 1830 – Report of Medical Examination	Form	New

ICR Details

OMB Control No: 2700-0170	ICR Reference No: 201902-2700-001
Status: Active	Previous ICR Reference No:
Agency/Subagency: NASA	Agency Tracking No:
Title: JSC Form 1830 – Report of Medical Examination
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/26/2019
	Date Received in OIRA: 02/27/2019
Terms of Clearance: This collection is approved based on the revised materials provided by the Agency.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved
Responses	30	0	0
Time Burden (Hours)	45	0	0
Cost Burden (Dollars)	2,250	0	0

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Abstract: Since the mid-1960s, neutral buoyancy has been an invaluable tool for testing procedures, developing hardware, and training astronauts. Neutrally buoyant conditions sufficiently simulate reduced gravity conditions, comparable to the environmental challenges of space. The Neutral Buoyancy Laboratory (NBL) at NASA Johnson Space Center (JSC) provides opportunities for astronauts to practice future on-orbit procedures, such as extravehicular activities (EVA), and to work through simulation exercises to solve problems encountered on-orbit. Per CX12-UWI0001, Neutral Buoyancy Laboratory Guest Diving Application Procedure, NASA allows non-NASA guest divers, typically non-federal photographers representing the media, opportunities to engage in the NBL diving experience. To participate, guest divers must present a dive physical, completed within one year of the targeted diving opportunity, for review by the NASA NBL Dive Physician. If the non-NASA guest diver does not have a current U.S. Navy, Association of Diving Contractors (ADC), or current Medical Examination of Divers (MA1) British standard for commercial diving physical, they are required to complete a medical examination, performed by a certified Diving Medical Examiner. The results of the physical will be documented on the JSC Form 1830/ Report of Medical Examination and presented to the NBL Dive Physician for review prior to participating in diving activities conducted at the JSC NBL.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 118	06/19/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 198	10/12/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
JSC Form 1830 – Report of Medical Examination	JSC Form 1830	Report of Medical Examination

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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	30	0	0	30	0	0
Annual Time Burden (Hours)	45	0	0	45	0	0
Annual Cost Burden (Dollars)	2,250	0	0	2,250	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: No

Burden Reduction Due to:

Short Statement: This is a new information collection

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Annual Cost to Federal Government: $2,707

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 02/27/2019

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