Form NF 57-03-09 NF 57-03-09 Liability Release and Assumption of Risk

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX
NOAA Form 57-03-09
(3-15)

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

LIABILITY RELEASE and ASSUMPTION of RISK
I, ______________________________________, am about to participate in a training
program sponsored by the National Oceanic and Atmospheric Administration (NOAA)
Diving Program described as follows: _______________________________________,
entirely upon my own initiative, risk, and responsibility.
•

I am aware of the inherent risks and hazards associated with diving, including, but not
limited to, barotrauma, lung over-expansion injuries, decompression sickness, and
drowning.

•

I understand that diving exposes my body to increased pressure and that I may be
injured as a result of participation in such activities despite following appropriate
practices and adhering to established decompression tables and procedures.

•

I also understand that diving is a physically strenuous activity and that I will be exerting
myself during this activity and that if I am injured as a direct or indirect result of
exposure to hyperbaric pressures that I assume the risk of said injuries and that I will
not hold the released parties responsible for the same.

•

I declare that I am in good mental and physical condition for diving, and that I am not
under the influence of any drugs that are contradictory to diving. If I am taking
medication, I declare that I have consulted with a physician and have approval to dive
while under the influence of such medication/drugs.

•

In consideration of being allowed to participate in this activity, I hereby personally
assume all risks in connection with any dive(s) for any harm, injury, damage or death
that may befall me, including all risks connected therewith, whether foreseen or
unforeseen. I further save and hold harmless said activity and NOAA, and any of its
employees, from any demand, claim or lawsuit for personal injury, property damage, or
wrongful death, by me, my family, heirs, executors, representatives, administrators and
assigns, arising out of my participation in this activity.

•

I further declare that I am of lawful age and legally competent to sign this liability
release. I hereby affirm that I have read this liability release and that I fully understand
its contents.

TRAINEE DIVER NAME (PRINTED)

TRAINEE DIVER SIGNATURE

DATE

SUPERSEDES EDITION (10-97)

RESET

PRA Public Burden Statement
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 0648-XXXX. 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 required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden to the NOAA Diving Center Executive Officer, NOAA Diving Program, 7600
Sand Point Way NE, Building 8, Seattle, WA 98115, 206-526-6460.
Privacy Act Statement
Authority: The collection of this information is authorized under 29 CFR 1910, Subpart T, Commercial Diving Operations. Additional
authorities include 29 U.S.C. 653, 655, 657; 40 U.S.C. 333; 33 U.S.C. 941; Secretary of Labor's Order No. 8-76 (41 FR 25059), 9-83 (48 FR
35736), 1-90 (55 FR 9033), 6-96 (62 FR 111), 3-2000 (65 FR 50017), 5-2002 (67 FR 65008), 5-2007 (72 FR 31160), or 4-2010 (75 FR
55355) as applicable, and 29 CFR 1911.
Purpose: NOAA is collecting this information to assess an individual’s medical fitness to dive, proficiency, and further training.
Information will also be used to ensure diving equipment is safe and well maintained and that all policies are being adhered to for safety
reasons. Aggregate data is used for annual reports and other leadership documents.
Routine Uses: NOAA will use this information in the determination of an individual’s medical fitness to dive. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related
purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of
Records Notice NOAA-10, NOAA Diving Program.
Disclosure: Furnishing this information is voluntary. However, the failure to provide complete and accurate information will exclude
the individual from NOAA’s Diving Program.