Form NF 57-03-38 NF 57-03-38 NOAA Diving Program Training Request and Authorization

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX

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

NOAA Form 57-03-38
(02-22)

NOAA DIVING PROGRAM TRAINING REQUEST AND AUTHORIZATION
This form will be used to identify prospective students for NOAA Diving Program classes. Submission of this form does not guarantee acceptance into a
particular course. Incomplete forms may be returned to the applicant.

APPLICANT INFORMATION

NAME (Last, First MI)

STUDENT TYPE
Select One

LINE OFFICE/UNIT OR AGENCY / EMPLOYER

NOAA Employee: CAPS/ GS

WORK ADDRESS
WORK PHONE NUMBER

NOAA Employee: Wage Mariner
NOAA Corps

EMAIL ADDRESS

To contact the student during training, supply an additional phone number:

PERSONAL CELL PHONE NUMBER

NOAA Contractor
I am not a NOAA Employee

TRAINING JUSTIFICATION (Non-NOAA personnel only)

COURSE and PAYMENT INFORMATION
COURSE NAME

COURSE START DATE

COURSE END DATE

COURSE FEE*

NOAA Diver

$

Divemaster

$

Diving Medical Technician

$

Tethered Communications

$
$

*Note: A course fee is only assessed for non-NOAA students. Contact [email protected] for current pricing.

TOTAL COST:

$

ELECTIVES
If attending NOAA Diver, please indicate the electives you plan on attending:

Drysuit

Nitrox

CERTIFICATIONS
DMT Applicants Only: Include a copy of your Basic Life Support Certification, and either a MPIC or EMT Certificate with application.
All Other Applicants: Include a copy of your CPR, AED, and First Aid certification cards with this application.
ALL certifications must be valid through Course End Date.

AUTHORIZATION
APPLICANT NAME

APPLICANT SIGNATURE

DATE

SUPERVISOR NAME

SUPERVISOR SIGNATURE

DATE

UNIT DIVING SUPERVISOR NAME

UNIT DIVING SUPERVISOR SIGNATURE

DATE

SUBMISSION INSTRUCTIONS
Fill out all applicable fields of this form, and then submit form to NDC electronically or via hard copy. Signatures are required if the
form is filed via hard copy, or if submitted electronically by the applicant. Signatures are not required if sent directly to NDC from the
e-mail account of the employee’s Unit Diving Supervisor. This form is due at least 60 calendar days before training begins; see the
NDC Training Calendar for specific application package deadlines.
E-mail the form to: [email protected]

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Subject line: Training Request

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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 5 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.