Form JSC Form 1830 JSC Form 1830 Report of Medical Examination

JSC FORM 1830 - REPORT OF MEDICAL EXAMINATION – PAGE 17 of 3

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. The OMB control number for this collection is 2700-XXXX and this information collection expires on MM/DD/YYYY. We estimate that it will take about 15 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: ([email protected]) Send only comments relating to our time estimate to this address.

Applicant Must Complete This Page

PLEASE TYPE OR PRINT CLEARLY IN DARK INK

1. Application For:

2. Last Name

First Name

Middle Name

     

     

     

     

3. E-mail

Telephone:

     

Work:      

Other:      

4. Street Address

City

State

Zip

     

     

     

     

5. DOB(M/D/Y)

6. Sex

7. Hair Color

8. Eyes Color

9. Type: NASA : Federal Employee

10. Employer:

     

     

     

     

Commercial Other      

     

11. Do you Currently Use Any Medication (Prescription or Nonprescription)? Yes No

If yes, give name, purpose, dosage, and frequency.      

12. Medical History -

Have you ever had or do you now have any of the following? Answer “yes” for every condition you have ever had in your life. Describe the condition and the approximate date of occurrence in the explanation box provided below.

Yes

No

Condition

Yes

No

Condition

Yes

No

Condition

a.

Frequent or severe headaches

i.

Stomach, liver, or intestinal trouble

q.

Motion sickness requiring medication

b.

Dizziness or fainting spell

j.

Kidney stone or blood in urine

r.

Military medical discharge

c.

Unconsciousness for any reason

k.

Diabetes

s.

Medical rejection by military service

d.

Eye or vision trouble (except glasses)

l.

Neurological disorders; epliepsy, seizures, stroke, paralysis, etc.

t.

Rejection for life or health insurance

e.

Hay fever or allergy

m.

Mental disorders of any sort depression, anxiety, etc.

u.

Admission to hospital

f.

Asthma or lung disease

n.

Substance dependence or failed a drug test (ever), or substance abuse or use of illegal substance in the last five years

v.

Other illness, disability, or surgery

g.

Heart or vascular trouble

o.

Alcohol dependence or abuse

h.

High or low blood pressure

p.

Suicide attempt

12 A. Explanations: If you answered YES to any of the above items, describe the condition and the approximate date of occurrence. Use additional page if needed.

     

13. Visits to Health Professional Within Last 3 Years.

Yes (explain below)

No

Date

Name, Address, and Type of Health Professional Consulted

Reason For Visit

     

     

     

     

     

     

     

     

     

NOTE: I declare under penalty of perjury that I have examined all the information on this form, and on the accompanying physician form, and it is true and correct to the best of my knowledge. I understand that anyone who knowingly gives a false statement about a material fact in this information, or causes someone else to do so, commits a crime and may be subject to a fine or imprisonment.

14. Signature of Applicant

15. Date

     

Examiner Must Complete and Sign This Page Please Type or Print Clearly In Dark Ink

CHECK EACH ITEM IN APPR. COLUMN

Normal

Abnormal

CHECK EACH ITEM IN APPR. COLUMN

Normal

Abnormal

16. Head, face, neck, and scalp

28. Vascular system (Pulse, amplitude and character, arms, legs, others)

17. Nose

29. Abdomen and viscera (Including hernia)

18. Sinuses

30. Anus (Not including digital examination)

19. Mouth and throat

31. Skin

20. Ears, general (internal and external canals: Hearing under item 49)

32. G-U system (Not including pelvic examination)

21. Ear Drums (Perforation)

33. Upper and lower extremities (Strength and range of motion)

22. Eyes, general (Vision under items 50 to 54)

34. Spine, other musculoskeletal

23. Ophthalmoscopic

35. Identifying body marks, scars, tattoos (Size & location)

24. Pupils (Equality and reaction)

36. Lymphatics

25. Ocular motility (Associated parallel movement, nystagmus)

37. Neurologic (Tendon reflexes, equilibrium, senses, cranial nerves, coordination, etc.)

26. Lungs and chest (Not including breasts examination)

38. Psychiatric (Appearance, behavior, mood, communication, and memory)

27. Heart (Precordial activity, rhythm, sounds, and murmurs)

39. General systemic

NOTES: Describe any above items checked “Abnormal” in detail. Enter item number before each comment. Use additional sheets if necessary.

     

40. Height

41. Weight

42. Hearing

Voice Test

Audiometer Threshold in Decibels

Right Ear

Left Ear

Right Ear

Left Ear

     

     

     

     

     

500

1000

2000

3000

4000

500

1000

2000

3000

4000

     

     

     

     

     

     

     

     

     

     

43. Distant Vision

44. Near Vision

45. Color Vision

Right

20/

     

Corrected to 20/

     

Right

20/

     

Corrected to 20/

     

Normal Abnormal

Left

20/

     

Corrected to 20/

     

Left

20/

     

Corrected to 20/

     

Both

20/

     

Corrected to 20/

     

Both

20/

     

Corrected to 20/

     

46. Field of Vision Normal Abnormal

47. Heterophoria 20’ (in prism diopters)

Esophoria

Exophoria

Right Hyperphoria

Left Hyperphoria

     

     

     

     

48. Blood Pressure (sitting mm of Mercury)

49. Pulse (Resting)      

50. Urinalysis Normal Abnormal (give results)

51. EKG (Date)

Systolic      

Diastolic      

Albumin      

Sugar      

MM

DD

YY

     

     

     

52. Other Tests Given

EKG Results:

     

     

53. Significant Medical History Yes No Abnormal Physical Findings Yes No Physician shall elaborate on all pertinent data; comment on all "YES" answers in the Medical History (pg 1, #12) and any abnormal findings of the exam. Physician may develop, by interview, any additional medical history deemed important, and record any significant findings here. ATTACH ADDITIONAL COMMENTS ON HISTORY & FINDINGS.

     

54. Applicant’s Name

55. Disqualifying Defects (List by item number)

     

     

56. Medical Examiner’s Declaration - I hereby certify that I have personally reviewed the medical history and personaly examined the applicant named on this medical examination report. This report, with any attachment, embodies my findings completely and correctly.

Exam Date

57. PHYSICIAN'S FULL NAME / ADDRESS / CITY / STATE / ZIP

MM

DD

YY

     

     

     

     

Physician’s Signature

Physician Telephone

(     )      

Privacy Act Notification Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the following statement is furnished to individuals supplying information for inclusion in the NASA Health Information Management System. AUTHORITY. The collection of this information is authorized by 5 USC §7901; 51 U.S.C. § 20113(a); 44 U.S.C. §3101; 42 CFR Part 2. PURPOSE. Information in this system of records is maintained on anyone receiving health care or health clearance through a NASA clinic or healthcare activity. The information will be used to assess the health of potential divers seeking clearance for use of NASA’s Neutral Buoyancy Laboratory. EFFECTS OF NOT PROVIDING. Failure to provide the requested information may result in denial of NASA facility use. ROUTINE USES. Any disclosures of information from this system of records will be compatible with the purpose for which the Agency collected the information. The records and information in this system may be disclosed: (1) to external medical professionals and independent entities to support internal and external reviews for purposes of medical quality assurance; (2) to the Office of Personnel Management, Occupational Safety and Health Administration, and other Federal or State agencies as required in accordance with the Federal agency's special program responsibilities; (3) to insurers for referrals or reimbursement; (4) to employers of non-NASA personnel in support of the Mission Critical Space Systems Personnel Reliability Program; (5) to international partners for mission support and continuity of care for their employees pursuant to NASA Space Act agreements; (6) to non-NASA personnel performing research, studies, or other activities through arrangements or agreements with NASA and for mutual benefit; (7) to the public of pre-space flight information having mission impact concerning an individual crewmember, limited to the crewmember's name and the fact that a medical condition exists; (8) to the public, limited to the crewmember's name and the fact that a medical condition exists, if a flight crewmember is, for medical reasons, unable to perform a scheduled public event following a space flight mission/landing; (9) to the public to advise of medical conditions arising from accidents, consistent with NASA regulations; and (10) in accordance with the following standard routine uses. Standard Routine Use No. 1—In the event this system of records indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether arising by general statute or particular program statute, or by regulation, rule or order issued pursuant thereto, the records in the SOR may be referred to the appropriate agency, whether Federal, State, local or foreign, charged with the responsibility of investigating or prosecuting such violation or charged with enforcing or implementing the statute, or rule, regulation or order issued pursuant thereto. Standard Routine Use No. 2—A record from this SOR may be disclosed to a Federal, State, or local agency maintaining civil, criminal, or other relevant enforcement information or other pertinent information, such as current licenses, if necessary to obtain information relevant to an agency decision concerning the hiring or retention of an employee, the issuance of a security clearance, the letting of a contract, or the issuance of a license, grant, or other benefit. Standard Routine Use No. 3—A record from this SOR may be disclosed to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant, or other benefit by the requesting agency, to the extent that the information is relevant and necessary to the requesting agency’s decision on the matter. Standard Routine Use No. 4—A record from this system may be disclosed to the Department of Justice when a) the Agency, or any component thereof; or b) any employee of the Agency in his or her official capacity; or c) any employee of the Agency in his or her individual capacity where the Department of Justice or the Agency has agreed to represent the employee; or d) the United States, where the Agency determines that litigation is likely to affect the Agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice or the Agency is deemed by the Agency to be relevant and necessary to the litigation provided, however, that in each case it has been determined that the disclosure is compatible with the purpose for which the records were collected. Standard Routine Use No. 5: A record from this system may be disclosed in a proceeding before a court or adjudicative body before which the agency is authorized to appear, when: a) The Agency, or any component thereof; or b) any employee of the Agency in his or her official capacity; or c) any employee of the Agency in his or her individual capacity where the Agency has agreed to represent the employee; or d) the United States, where the Agency determines that litigation is likely to affect the Agency or any of its components, is a party to litigation or has an interest in such litigation, and the use of such records by the Agency is deemed to be relevant and necessary to the litigation, provided, however, that in each case, the Agency has determined that the disclosure is compatible with the purpose for which the records were collected. Standard Routine Use No. 6—A record from this SOR may be disclosed to appropriate agencies, entities, and persons when (1) NASA suspects or has confirmed that the security or confidentiality of information in the system of records has been compromised; (2) NASA has determined that as a result of the suspected or confirmed compromise there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of this system or other systems or programs (whether maintained by NASA or another agency or entity) that rely upon the compromised information; and (3) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with NASA’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm. Standard Routine Use No. 7—A record from this system may be disclosed to contractors, grantees, experts, consultants, students, and others performing or working on a contract, service, grant, cooperative agreement, or other assignment for the federal government, when necessary to accomplish an Agency function related to this system of records. Standard Routine Use No. 8—A record from this system may be disclosed to a Member of Congress or staff acting upon the Member’s behalf when the Member or staff requests the information on behalf of, and at the request of, the individual who is the subject of the record.

JSC Form 1830 (Rev April 12, 2019) (MS Word October 2009) NRRS 8/109