NIST-986 Health Record

OMB Control Number: 0693-0080 Expiration Date: 07/31/2021

NIST-986 (REV. 4-2021) NIST P 7100.00

U.S. DEPARTMENT OF COMMERCE NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY

HEALTH RECORD

Date:

     

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with information solicited. All information listed below is given voluntarily and is confidential. It will be used only by the Health Unit in a medical emergency.

Name (Last, first, middle initial)

     

Date of Birth

Social Security Number/Passport Number/Driver’s License Number

Male

     

     

Female

Work Telephone Number

Email Address

Mail Stop

     

     

     

Job Title

Division

Building

Room

     

     

     

     

Supervisor/Sponsor

Supervisor/Sponsor Telephone Number

     

     

Home Address

Personal Telephone Number

     

     

Private Physician (Name, address, telephone number)

     

Emergency Contact(s)

1.

Name:

     

Relationship:

_______________________

Phone #:

     

2.

Name:

     

Relationship:

__________________________

Phone #:

     

I give consent to the above named person(s) to access any and all medical information related to me.

I am the only person authorized to access any and all medical information related to me. (In the case of incapacitation, state/federal laws would take effect.)

Significant Medical Problems

Details

Allergies - non-medication

Arthritis/Chronic Pain Asthma/COPD/Emphysema Other Lung Disorders Cancer Diabetes High Blood Pressure Kidney Disorders Mental Illness/Anxiety/Depression Seizures/Neurological Disorders Stroke/Heart/Cardiovascular Diseases Other:      

     

     

Allergies - medications

     

Current Medications (and date started)

     

Chaperone Requested:

Yes

No

Preferred Pharmacy:

     

Pharmacy Address:

     

Phone #:

     

By signing below, I agree to the following: The above information is correct and true to the best of my knowledge. I have received and understand the Notice of Privacy Practices, Health Unit Rights and Responsibilities, and Chaperone Policy. I have received and understand the Consent for Care and fully consent to treatment.

Signature:

Date:

OMB Control Number:0693-0080 Expiration Date: 07/31/2021

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 0693-0080. Without this approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to the National Institute of Standards and Technology, Attn: Stephen Banovic, [email protected].

Privacy Act Statement

Authority:  The collection of this information is authorized under The National Institute of Standards and Technology Act, as amended, 15 U.S.C. 271 et seq. (which includes Title 15 U.S.C. 272) and section 12 of the Stevenson-Wydler Technology Innovation Act of 1980, as amended, 15 U.S.C. 3710a. Includes the following, with all revisions and amendments: 5 U.S.C. 301; 44 U.S.C. 3101; E.O. 12107, E.O. 13164, 41 U.S.C. 433(d); 5 U.S.C. 5379; 5 CFR Part 537; DAO 202-957; E.O. 12656; Federal Preparedness Circular (FPC) 65, July 26, 1999; DAO 210-110; Executive Order 12564; Public Law 100-71, dated July 11, 1987. Executive Orders 12107, 12196, and 12564 and 5 U.S.C. chapters 11, 33, and 63.

Purpose:  The Office of Safety, Health, and Environment (OSHE) supports the National Institute for Standards and Technology in carrying out its mission safely and in maintaining safety as an integral core value and vital part of the NIST culture. The NIST Health Unit will use this information to record medical or health information for individuals seeking medical care on NIST campus; for recording of medical or safety equipment or incidents; to refer information required by applicable law to be disclosed to a Federal, State, or local public health service agency, concerning individuals who have contracted certain communicable diseases or conditions. Such information is used to prevent further outbreak of the disease or condition; to disclose information to the appropriate Federal, State, or local agency responsible for investigation of an accident, disease, medical condition, or injury as required by pertinent legal authority; to disclose information, when an individual to whom a record pertains is mentally incompetent or under other legal disability, to any person who is responsible for the care of the individual, to the extent necessary; to disclose to the Office of Workers' Compensation Programs in connection with a claim for benefits filed. Disclosure of this information is also subject to all the published routine uses as identified in the Privacy Act System of Records Notices:

Commerce/DEPT-18:  Employees Personnel Files Not Covered by Notices of Other Agencies

OPM/GOVT-10:  Employee Medical File System Records

Disclosure:  Furnishing this information is voluntary.  For Health Unit information collections, individuals have opportunity to decline providing information, however, care may be affected and future retrievability will be impacted. Submitting voluntary information constitutes your consent to the use of the information for the stated purpose. When you submit the form, you are indicating your voluntary consent for NIST to use of the information you submit for the purpose stated. 

NIST-986 (REV. 4-2021)