Form NF 57-03-41 NF 57-03-41 Diving Activity Resume

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX
NOAA Form 57-03-41
(3-15) Page 1 of 2

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

DIVING ACTIVITY RESUME
DIVER INFORMATION
APPLICANT NAME (Last, First MI)

BIRTHDATE

ORGANIZATION

POSITION HELD

MAILING ADDRESS

CITY

E-MAIL ADDRESS

WORK PHONE

LAST 4 of SSN

DATE

STATE

ZIP

WORK FAX

NAME of SUPERVISOR / CONTACT

PHONE

DIVING CERTIFICATIONS – Attach copies of all certifications listed below.
Organization
Certification Level / Depth
Date

MEDICAL CERTIFICATIONS – Attach copies of all certifications listed below.
Agency
Level

Location

Diving Instructor

Date (initial)

Date (current)

CPR
First-Aid
O2 Admin
EMT
DMT
Other
DIVING ACTIVITY
Number of years diving

Date of last dive

Total number of dives

Total hours under water

Greatest depth of any dive

Greatest depth in the past 12 months

Number of dives in the past 6 months

Number of dives in the past 12 months

Date of last Dry-Suit dive

Date of last Nitrox / Trimix dive

DIVING DEPTHS – Indicate cumulative number of dives by depth, by year. Indicate most recent year first.
YEAR

0 – 30’ fsw

31 – 60’ fsw

61 – 100’ fsw

RESET page 1

101 – 130’ fsw

Deeper than 130’ fsw

NOAA Form 57-03-41
(3-15) Page 2 of 2

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

DIVING ACTIVITY RESUME
EXPERIENCE – Indicate the number of dives for each type of diving experience listed below. If zero, leave blank.
Fresh Water

Visibility > 20’

Decompression

Search & Recovery

Salt Water
Blue Water
Rivers
Dive Chamber
Dive Habitat
Lockout

Visibility = 5 – 20 ‘
Visibility = 1 – 5’
Visibility < 1’
Visibility = 0
Water Temp < 50°
Water Temp = 51 - 70°

Saturation
Closed Circuit
Surface Supplied
Dry Suit
Nitrox
Heliox

Photography / Video
Navigation
Salvage / Lift Bag
Ship Husbandry
From Small Boat
Shore / Beach Entry

Night Diving
Coral Reef
Kelp
Ice Diving / Polar
Under Ice
Wreck Penetration

Water Temp > 71°
Current < 1 knot
Current = 1 – 3 knots
Current > 3 knots
Depths > 130’
Drift Diving

Trimix
Dive Computer
Altitude (> 1000’)
Research / Survey
Coring / Collecting
Commercial Diving

Heavy Surf Entry
Pier / Dock Entry
Underwater Assembly
Recreational Sport
Instructional
Observational

Cave Penetration

Skin / Free Diving

Military Diving

Life Saving

Additional diving experience

Geographical locations of diving experience

SELF ASSESSMENT – State objectives and intent for NOAA Diving Program certification.

Have you ever run out of air during a dive?
□ YES
Have you ever been treated in a hyperbaric chamber for diving related accident?
□ YES
Have you ever experienced symptoms of de-compression sickness (DCS)?
□ YES
Have you ever experienced a pulmonary barotrauma, gas embolism or near drowning?
□ YES
Applicable incident or accident reports are attached for the “Yes” responses listed above.
□ YES
DIVER REFERENCES – Provide at least two references familiar with your diving experience and abilities.
NAME

ORGANIZATION

LOCATION

PHONE

NAME

ORGANIZATION

LOCATION

PHONE

NAME

ORGANIZATION

LOCATION

PHONE

□
□
□
□
□

NO
NO
NO
NO
NO

VERIFICATION – I have reviewed and found this resume to be a thorough and honest representation of my diving history.
APPLICANT NAME

APPLICANT SIGNATURE

DATE

UNIT DIVING SUPERVISOR NAME

UNIT DIVING SUPERVISOR SIGNATURE

DATE

RESET page 2

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 1 hour 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.