NF 57-03-38 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
(12-23)

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

CANDIDATE INFORMATION
NAME (Last, First MI)

CANDIDATE TYPE
NOAA Employee: CAPS/ GS

LINE OFFICE /UNIT, OR AGENCY /EMPLOYER

NOAA Professional Mariner
WORK ADDRESS

WORK PHONE NUMBER

EMAIL ADDRESS*

PERSONAL CELL PHONE NUMBER*

NOAA Corps
NOAA Contractor
I am not affiliated with NOAA

*Military candidates should supply a non-military email. All candidates: please supply an additional phone number so that instructors can contact you during training.

TRAINING JUSTIFICATION (Non-NOAA personnel only)

COURSE and PAYMENT INFORMATION
SELECT OR WRITE IN COURSE NAME BELOW

COURSE START DATE

COURSE END DATE

COURSE FEE*
$

Other:

$

*Note: A course fee is only assessed for non-NOAA candidates. See our website for fees www.omao.noaa.gov/ndp/diver-courses, or email [email protected].

NOAA DIVER APPLICANTS
The following is required for NOAA Diver Course candidates. Information about prior diving experience may be used to grant you a deeper depth
authorization. Note: none of the following will impact course selection.

If attending NOAA Diver, please indicate the elective(s) you plan on attending:
Do you have any prior diving experience?

Yes

No

Drysuit

Nitrox

None

If yes, summarize the most advanced depth & training you have completed:

CERTIFICATIONS (Note: ALL certifications must be valid through the Course End Date)
Medical Course Candidates Only: Include a copy of your Basic Life Support Certification, and either a MPIC or EMT Certificate with application.
NOAA Diver Candidates: Include copies of your CPR/AED, & First Aid certification cards with this application.
Divemaster Candidates: Include copies of your CPR/AED, First Aid, & Emergency Oxygen Administration certification cards with this application.

AUTHORIZATION

CANDIDATE NAME

CANDIDATE 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 email 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.
Email the form to: [email protected]

Clear Form

Save As

Subject line: Training Request

Print

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.