Form NF 57-03-54 NF 57-03-54 Report of Medical History - Annual Update

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX
NOAA Form 57-03-54
(06-17)

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

REPORT OF MEDICAL HISTORY – ANNUAL UPDATE

LAST NAME

FIRST NAME

MIDDLE NAME

WORK ADDRESS

DATE OF BIRTH

DATE

WORK PHONE NUMBER
WORK E-MAIL ADDRESS
CELL PHONE NUMBER

STATEMENT OF PRESENT HEALTH

CURRENT PRESCRIPTION AND NON-PRESCRIPTION MEDICATIONS
(Indicate dosage, frequency and condition being treated)

AGE

GENDER

HEIGHT

WEIGHT

ALLERGIES
(List all insect bites / stings, foods and medicines)

MEDICAL HISTORY OF THE PAST YEAR: Have you had any of the following in the past 12 months? Check each item. Explain any item that has
changed since you last submitted a Report of Medical History form to the NOAA Diving Program. Physician signature is not required.
YES
Tuberculosis or positive TB test
Exposed to someone who had tuberculosis
Asthma or any breathing difficulty
Lung squeeze or collapsed lung (pneumothorax)
Thyroid trouble or goiter
Ear infection or ruptured ear drum
Inability to equalize middle ear pressure
Bone, joint or other deformity
High or low blood sugar
Unexplained weight loss or gain
Head injury, memory loss or amnesia
Concussion or period of unconsciousness
Seizures, convulsions, epilepsy or fits
Dizziness or fainting spells
Indicate the type and frequency of use for the following.
Alcohol
Tobacco

NO

YES

NO

Aneurysm, frequent or severe headaches
Other neurologic disorder or injury
Prolonged bleeding, blood clot or embolism
Heart murmur or other disorder
High or low blood pressure
Abnormal heart anatomy or patent foramen ovale
Depression, anxiety or claustrophobia
Been evaluated or treated for a mental condition
Difficulty performing moderate to heavy exercise
Diabetes, high cholesterol, stroke or heart disease
Parent or sibling with diabetes, stroke or heart disease
Treated in a decompression chamber
Decompression illness (symptoms of both AGE/DCS)
Currently pregnant/ may be pregnant (women only)
Illegal drugs

Indicate date, location and reason for each hospitalization and surgery, had or advised to have. Indicate the reasons for any declined surgery.

Provide a detailed explanation for each item checked “YES” in either Medical History section. Add additional pages if necessary.

APPLICANT CERTIFICATION:

______ I have reviewed the attached medical information and consider the application package to be complete.
______ I acknowledge that it is my responsibility to notify the NOAA Diving Medical Office of any illness or injury requiring
medical treatment and/or surgery.
______ I acknowledge it is my responsibility to notify my UDS and the onsite diving supervisor of any conditions or restrictions
that will affect my diving on any given day. Failure to do so could compromise the mission and endanger myself or my fellow
divers.
I certify that I have reviewed the medical information provided by me. It is true and complete to the best of my knowledge.
APPLICANT NAME
APPLICANT SIGNATURE
DATE

NOAA DIVING MEDICAL OFFICER APPROVAL:
I have reviewed the attached medical information and have found the applicant named above to be:
Medically cleared for NOAA diving duty
Not medically cleared for NOAA diving duty
DIVING MEDICAL OFFICER NAME

DIVING MEDICAL OFFICER SIGNATURE

DATE

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.