JSC Neutral Buoyancy Guest Diver Physical Supporting Statement A_120418

JSC Form 1830 – Report of Medical Examination

Support Statement for Information Collection Requirements

Form names and numbers: JSC Form 1830 – Report of Medical Examination

TYPE OF ACTION: NEW

OMB Control Number: 2700-XXXX

OMB 83I states: A Supporting Statement, including the text of the notice to the public required by 5 CFR 1320.5(a)(i)(iv) and its actual or estimated date of publication in the Federal Register, must accompany each request for approval of a collection of information. The Supporting Statement must be prepared in the format described below, and must contain the information specified in Section A below. If an item is not applicable, provide a brief explanation. When Item 17 of the OMB Form 83-I is checked "Yes", Section B of the Supporting Statement must be completed. OMB reserves the right to require the submission of additional information with respect to any request for approval.

Part A. Justification

1. Need for the Information Collection: Explain the circumstances that make the collection of information necessary. Identify any legal or administrative requirements that necessitate the collection. Attach a copy of the appropriate section of each statute and regulation mandating or authorizing the collection of information.

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. NASA hires individuals with demonstrated diving experience as NBL Working Divers in teams comprised of four divers; two safety divers, one utility diver, and one cameraman to assist astronauts practice various tasks encountered in space.

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. The associated cost for guest divers to complete the medical examination will vary, typically based on the guest diver’s insurance.

2. Use of this Information: Indicate how, by whom, and for what purpose the information is to be used. Except for a new collection, indicate the actual use the agency has made of the information received from the current collection.

A completed dive physical (U.S. Navy, ADC, MA1, or JSC Form 1830/Report of Medical Examination, with test results attached as applicable), must be submitted by the non-NASA guest diver to enable NASA to validate an individual’s physical ability to dive in the NBL at NASA Johnson Space Center (JSC). The completed dive physical/JSC Form 1830 will be protected in accordance with the Privacy Act of 1974. Records will be retained in accordance with NASA Records Retention Schedules.

3. Use of Information Technology: Describe whether, and to what extent, the collection of information involves the use of automated, electronic, mechanical, or other technological collection techniques or other forms of information technology, e.g., permitting electronic submission of responses, and the basis for the decision for adopting this means of collection. Also describe any consideration of using information technology to reduce burden.

NASA JSC HTSG provides the non-NASA guest diver with an email using the JSC Clinic Online Portal to collect any medical information necessary. This JSC-KRYPTIQ email link assures confidentiality. The Dive Physical with test results are attached via a JSC-KRYPTIQ email by calling the NBL Human Test Support Group (HTSG) at (281) 792-5722/5723/5729. This collection reduces paperwork as required by the Paperwork Reduction Act of 1995. The collection of this data will not be published and not intended to be disseminated to public. https://kryptiq.jsc.nasa.gov/portal/default.aspx

4. Efforts to Identify Duplication: Describe efforts to identify duplication. Show specifically why any similar information already available cannot be used or modified for use for the purposes described in Item 2 above.

N/A

5. Burden on Small Business: If the collection of information impacts small businesses or other small entities (Item 5 of OMB Form 83-I), describe any methods used to minimize burden. If the collection does not have a significant impact on small business, you may state something to the effect that “Collection of this information does not have a significant impact on small businesses.”

Collection of this information does not have a significant impact on small businesses.

6. Consequences of Not Collecting the Information: Describe the consequence to Federal program or policy activities if the collection is not conducted or is conducted less frequently, as well as any technical or legal obstacles to reducing burden.

Non-NASA Guest Diving will not occur if we are unable to verify a person’s Diving Physical.

7. Special Circumstances: Explain any special circumstances that would cause an information collection to be conducted in a manner: (Exceptions/special circumstances must be explained if the collection of information is not conducted in a manner consistent with the guidelines for PRA in 5 CFR 1320.6” below)

NASA does not anticipate circumstances arising that would cause information to be collected in a manner that requires explanation of special circumstances.

• Requiring respondents to report information to the agency more often than quarterly; -

• Requiring respondents to prepare a written response to a collection of information in fewer than 30 days after receipt of it;-

• Requiring respondents to submit more than an original and two copies of any document; -

• Requiring respondents to retain records, other than health, medical, government contract, grant-in-aid, or tax records for more than 3 years; - In connection with a statistical survey, that is not designed to produce valid and reliable results that can be generalized to the universe of study;-

• Requiring the use of a statistical data classification that has not be reviewed and approved by OMB; That includes a pledge of confidentiality that is not supported by authority established in statue or regulation, that is not supported by disclosure and date security policies that are consistent with the pledge, or which unnecessarily impedes sharing of data with other agencies for compatible confidential use; or

• Requiring respondents to submit proprietary trade secret, or other confidential information unless the agency can demonstrate that it has instituted procedures to protect the information’s confidentiality to the extent permitted by law.

8. Consultation and Public Comments: If applicable, provide a copy and identify the date and page number of publication in the Federal Register of the agency’s notice, required by 5 CFR 1320.8(d), soliciting comments on the information collection prior to submission to OMB. Summarize public comments received in response to that notice and describe actions taken by the agency in response to these comments. Specifically address comments received on cost and hour burden.

60-day FRN: Federal Register Volume 83, Number 118, on June 19, 2018. No comments were received.

30-day FRN: Federal Register Volume 83, Number 198, on October 12, 2018. No comments were received.

9. Payments to Respondents: Explain any decision to provide any payment or gift to respondents, other than remuneration of contractors or grantees.

N/A

9. Assurance of Confidentiality: Describe any assurance of confidentiality provided to respondents and the basis for the assurance in statute, regulation, or agency policy.

NASA JSC HTSG provides the non-NASA guest diver with an email using the JSC Clinic Online Portal to collect any medical information necessary. This JSC-KRYPTIQ email link assures confidentiality. https://kryptiq.jsc.nasa.gov/portal/default.aspx

The Office of Chief Health and Medical Officer felt that NASA 10HIMS was sufficient coverage for the NBL use form.  Thus, the currently published SORN Federal Register location is 15-101, 80 FR 214, pp. 68568-68572.   See that for yourself in the publication at https://www.gpo.gov/fdsys/pkg/FR-2015-11-05/pdf/2015-28254.pdf.

9. Sensitive Questions: Provide additional justification for any questions of a sensitive nature, such as sexual behavior and attitudes, religious beliefs, and other matters that are commonly considered private. This justification should include the reasons why the agency considers the questions necessary, the specific uses to be made of the information, the explanation to be given to persons from whom the information is requested, and any steps to be taken to obtain their consent.

N/A

9. Respondent Burden Hours and Labor Costs: Provide estimates of the hour burden of the collection of information.

.

Burden Calculation:  Estimation of Respondent Burden Hours
	Number of Respondents	Number of Responses Per Respondent	Number of Total Responses	Response Time	Respondent Burden Hours
Survey 1	30	1	30	1.5	45
Burden Calculation:  Labor Cost of Respondent Burden
	Number of Total Responses	Response Time	Respondent Hourly Wage	Labor Burden per Response	Total Labor Burden
Survey 1	30	1.5	50	75	2,250

13. Estimates of Cost Burden to the Respondent for Collection of Information: Provide an estimate for the total annual cost burden to respondents or record keepers resulting from the collection of information. (Do not include the cost of any hour burden shown in Items 12 and 14).

14. Cost to the Federal Government: Provide estimates of annualized costs to the Federal government.

The estimated annual cost to NASA for the review of reports under this ICR is $2,707.35.  This estimate is calculated by multiplying the number of reports, 30, by an average 1 hours of Government review time, at an average rate of $90 (.5 Med Level III & .5 Med Level 5, pay scale) totaling $2,707.35.

Task	Rate of pay/hour	Percent of time	Total hours	Total
NASA Contract Technician	$ 50.49	1%	15	$  757.35
NASA Contractor Medical Officer	$130.00	1%	15	$    1,950
Total for  projects/year				$  2,707.35

15. Changes in Burden: Explain the reasons for any program changes or adjustments reported in Items 13 or 14 of the OMB Form 83-I, if applicable.

N/A

16. Publication of Results: For collections of information whose results will be published, outline plans for tabulation and publication. Address any complex analytical techniques that will be used. Provide the time schedule for the entire project, including beginning and ending dates of the collection of information, completion of report, publication dates, and other actions.

The collection of this data will not be published.

17. If seeking approval to not display the expiration date for OMB approval of the information collection, explain the reasons that display would be inappropriate. (NASA will display the expiration date within the required PRA Statement.)

N/A

18. Explain each exception to the certification statement identified in Item 19, "Certification for Paperwork Reduction Act Submissions," of OMB Form 83-I. (NASA will display the expiration date within the required PRA Statement.)

The NASA information collection sponsor (civil service employee) must address the certification below, and enter their name and position title. The NASA Office of the Chief Information Officer must concur on any exceptions requested by the information collection sponsor, or the package will not be forwarded to OMB.

The proposed collection of information –

(a) is necessary for the proper performance of the functions of NASA, including that the information to be collected will have practical utility;

(b) is not unnecessarily duplicative of information that is reasonably accessible to the agency;

(c) reduces to the extent practicable and appropriate the burden on persons who shall provide information to or for the agency, including with respect to small entities, as defined in the Regulatory Flexibility Act (5 U.S.C. 601(6)), the use of such techniques as:

(1) establishing differing compliance or reporting requirements or timelines that take into account the resources available to those who are to respond;

(2) the clarification, consolidation, or simplification of compliance and reporting requirements; or

(3) an exemption from coverage of the collection of information, or any part thereof;

(d) is written using plain, coherent, and unambiguous terminology and is understandable to those who are targeted to respond;

(e) indicates for each recordkeeping requirement the length of time persons are required to maintain the records specified;

(f) has been developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected, including the processing of the information in a manner which shall enhance, where appropriate, the utility of the information to agencies and the public;

(g) when applicable, uses effective and efficient statistical survey methodology appropriate to the purpose for which the information is to be collected; and

(h) to the maximum extent practicable, uses appropriate information technology to reduce burden and improve data quality, agency efficiency and responsiveness to the public; and

(i) will display the required PRA statement with the active OMB control number, as validated on www.reginfo.gov

The NASA office conducting or sponsoring this information collection certifies compliance with all provisions listed above.

Name: __Rebekah D. Reed, Ph.D., JA_________________

Title: ___Chief, Space and Occupational Medicine Branch____________

Email address or Phone number: [email protected] / (281) 483-3140

Date: _12-04-2018____

(Certifying individual must be a civil service employee)

B. Collections of Information Employing Statistical Methods (If applicable)

Section B must be completed if the information collected from covered members of the public will be used to statistical purposes

N/A – Will not be used for statistical purpose

6