Flight Analog Projects (FAP) Crew Selection Questionnaire

The following questions determine the flight analog study for which you are better suited. This site does not use cookies or tracking.

Your responses will be reviewed. By submitting this form, you consent to adding your responses to the analog subject registry. After reviewing your responses, further information may be requested. You may withdraw your information from this registry at any time by sending an e-mail to the recruitment team at [email protected] or [email protected]

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 information collection is 2700-xxxx and it expires on xx/xx/xxxx. We estimate that it will take about 10 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.

Privacy Act Notification

Furnishing us this information is voluntary. However, failing to provide all or part of the information may prevent an accurate and timely decision on your application.

We will use the information to determine eligibility for the Flight Analog project. We may also share your information for the following purposes, called routine uses:

Standard Routine Use No. 1 –

The information will help to perform initial screening of the participants to become a ground study subject for missions such as HERA. The records and information in this system may be shared with following NASA/Contractor personnel:

1) NASA Institutional Review Board (IRB)

2) Principal Investigators/Study Scientists

3) Test Subject Screening and Recruiting Coordinator

4) Study related personnel

Standard Routine Use No. 2 –

This information in conjunction with additional information collected via other downstream processes will be evaluated for approval/disapproval of the applicant to become ground study subject.

Standard Routine Use No. 3 –

This information in conjunction with additional information collected via other downstream processes will be used to assess compatibility with research protocol requirements for data collection and ground mission assignments if the applicant is selected to become a ground study subject.

A list of additional routine uses is available in our Privacy Act System of Records Notices (SORN), entitled Human Experimental and Research Data Records, as published in the Federal Register on 11/5/2015 at 80 FR 68568. Additional information, and a full listing of all of our SORNs, is available on our website at https://www.nasa.gov/content/nasa-privacy-act-system-of-records-notices-sorns

Are you a United States citizen?

Yes

No

First Name:

Middle Name:

Last Name:

Email Address:

Birthdate:

Gender

Male

Female

Height (in inches):

Body Mass Index (BMI):

MRI - Do you have any metal in your body other than dental work or most joint replacements?

Yes

No

Are you claustrophobic?

Yes

No

Do you have any of the following?

Allergies (including food)

GI Disorders

Dietary Limitations

Any cardiovascular issues?

Yes

No

Any neurological problems?

Yes

No

Any musculoskeletal problems?

Yes

No

Are you taking any medications?

Yes

No

Any sleep disorders such as sleep walking or use of sleep aids?

Yes

No

Any psychiatric disorders or history of mental illness?

Yes

No

Any motion sickness (not a disqualifier)?

Yes

No

Any pharmacological treatment for ADHD?

Yes

No

Any history of kidney stones?

Yes

No

Any history of ulcers?

Yes

No

Any history of epilepsy or other disorders of the brain?

Yes

No

Any history of blood clots?

Yes

No

Any history of close relatives with seizures?

Yes

No

Are you currently on Bis-Phosphonate (for example, Fosamax, Boniva, or Reclast)?

Yes

No

Are you currently on any medication that might increase chances of seizures?

Yes

No

Are you pregnant?

Yes

No

Are you at least 6 months post partum?

Yes

No

Have you completed Military Officer training?

What is your highest level of education in a STEM related field?

Bachelor

Master of Science

PhD

Medical Doctor

Other

What languages are you fluent in reading and writing?

English

Russian

What languages are you verbally proficient?

English

Russian

Length of isolation?

45 days

4 months

8 months

12 months

Submitting voluntary information constitutes your consent to the use of the information for the stated purpose.

By clicking the 'Apply' or 'Submit' buttons on any of the site’s forms, you are providing voluntary consent to use the information submitted for the purpose stated.

The final determination for clearance is the responsibility of NASA. You may be provided the opportunity to personally explain, refute, or clarify any information before a final decision is made.

Typically, all applicants will be contacted within 5 to 7 business days following the submission of their application.

I declare that I have examined all the information on this form and certify it is true and correct to the best of my knowledge.

Apply