NF 57-10-01 NOAA Health Services Questionnaire

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

NOAA Form 57-10-01
(03-16) Page 1 of 5

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

HEALTH SERVICES QUESTIONNAIRE

Application for Medical Qualification to Embark a NOAA Ship

Section I: Applicant Information
Applicant Name (Last, First Middle)

Year of Birth

Office, Laboratory or Institution Name

Work Phone

Work Address

Cell Phone

City

State

Zip Code

E-mail Address
Emergency Contact Name
Address
Project Dates

City

Today’s Date

Home Phone

Relationship

(Check one preferred contact
phone number above)
Cell Phone

State

Home Phone

Start

Zip Code
End

Project Ship(s)
Position

Scientist

Contractor

Teacher at Sea

Volunteer

Other (specify below)
___________________________

Section II: Current Health Information – (provide additional information on page 4 if needed)
List all health problems / medical conditions which regularly require a physician’s attention.
1.
2.
None
3.
4.
List all medications (prescription and non-prescription) you currently take.
1.
5.
2.
6.
None
3.
7.
4.
8.
List all health problems / medical conditions which do not require a physician’s attention or medication.
1.
2.
None
3.
4.
List major surgeries, hospitalizations, and emergency room visits with dates.
1.
2.
None
3.
4.
List all known allergies and subsequent reactions.
Allergy
Reaction
1.
1.
None
2.
2.
3.
3.

NOAA Form 57-10-01
(03-16) Page 2 of 5

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

HEALTH SERVICES QUESTIONNAIRE

Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Section III: General Screening
Indicate any medical condition experienced during adulthood.
Yes

No

Yes

No

Cancer

Epilepsy / Seizures

Tuberculosis

Impaired Mobility

Asthma

Severe Hearing Loss

Hepatitis

Severe Visual Impairment

Chronic Cough

Severe Motion Sickness

Severe Depression

Fainting / Loss of Consciousness

Untreated Dental Issues

Recent unexplained weight gain > 20 lbs

Currently Pregnant

Recent unexplained weight loss > 20 lbs

Explain any positive response(s) below.

Section IV: Cardiac Screening
Indicate any cardiac condition experienced during adulthood and the applicable test result.
Yes

No

Yes

No

Abnormal EKG
Heart Attack

Hypertension
___________

Shortness of Breath
Chest Pain

Recent Blood Pressure Reading
Diabetes

__________

Recent HbA1c Reading

Explain any positive response(s) below.

Section V: Immunization Screening
Indicate the applicable test result and the dates for the following screening and immunization;
1.

Tuberculosis (TB): A tuberculosis skin test or TST (purified protein derivative, PPD), a QuantiFERON-TB blood test, or a TSpot blood test is required within the 12 months preceding the project or cruise end date. Results are documented on the
“NF 57-10-02 - Tuberculosis Screening Document” and this document must be submitted with the NHSQ for medical
clearance to embark.

2.

Tetanus booster

Date _____________

NOAA Form 57-10-01
(03-16) Page 3 of 5

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

HEALTH SERVICES QUESTIONNAIRE

Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Section VI: Functional Abilities Screening
Indicate the ability to perform the following tasks.
Yes

No
Step over a 24 inch high door sill
Walk on a steel deck for 4-8 hours per day
Stand on a steel deck for 4-8 hours per day
Walk on slippery or uneven walking surfaces
Climb stairs
Carry 15 lbs
Don a survival suit in less than one (1) minute
Ascend a rope ladder with rigid rungs
Descend a rope ladder with rigid rungs
Hear a ship’s general alarm (hearing aid permitted)

Explain any negative response(s) below and indicate any medical condition or physical limitation which may adversely affect
qualification for sea duty.

Section VII: Applicant Certification
I certify the information provided is true, accurate, and complete to the best of my knowledge. I acknowledge that falsification
of any information on this government document is punishable by fine, imprisonment, or both.

Applicant Signature

For assistance completing this form, contact;
1.
MOC-A Health Services in Norfolk, VA
2.
MOC-P Health Services in Newport, OR

Date

Phone: (757) 441-6320
Phone: (541) 867-8820

Fax: (757) 441-3760
Fax: (541) 867-8856

MOC Health Services Use Only
Applicant is medically cleared for sea duty aboard a NOAA ship by history.
Applicant is medically disqualified for sea duty aboard a NOAA ship by history.
Additional information is needed to determine medical clearance for sea duty.
MOC Health Services Medical Officer Signature

Date

NOAA Form 57-10-01
(03-16) Page 4 of 5

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

HEALTH SERVICES QUESTIONNAIRE

Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Continuation Page
Use the space provided below to further explain any medical condition indicated on the previous pages.

SUPERSEDES NOAA Form 57-10-01 (12-11)

RESET

NOAA Form 57-10-01
(03-16) Page 5 of 5

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

HEALTH SERVICES QUESTIONNAIRE

Application for Medical Qualification to Embark a NOAA Ship

INSTRUCTIONS
The Health Services Questionnaire must be submitted to MOC Health Services 30 days in
advance of the project start date. The form must be legible and complete. Unreadable or incomplete
forms will be returned to the applicant. Late submissions may result in delayed qualification of sea duty
past the project start date.
All positive responses in the General Screening and Cardiac Screening sections require a
detailed explanation in the space provided. The Continuation Page may be used if more space is
needed. An indication of hypertension requires the most recent blood pressure reading. An indication
of diabetes requires the most recent glycated hemoglobin (HbA1c) reading.
All persons embarked aboard a NOAA ship must have a test for tuberculosis (TB) within the
12 months preceding the project end date. MOC Health Services accepts three tests to detect exposure
to the TB bacteria; the Purified Protein Derivative (PPD or TB skin test), the QuantiFERON-TB test (QFT or
TB blood test), and the T-spot blood test. PPD results must be recorded in millimeters (mm) and not
documented as positive or negative. QuantiFERON-TB and the T-spot results must be indicated as
negative, positive, or indeterminate.
All persons embarked on a NOAA ship must be able to perform normal work
functions and minimal personal emergency response functions while the ship is
underway. During an abandon ship event, personnel may have to don a survival suit
and/or descend a rope ladder to a life raft or rescue craft. Personnel deploying in
small boats for operations may have to ascend and descend a rope ladder. A rope
ladder (as pictured to the right) is a heavy duty ladder with rigid rungs that hangs
over the side of the ship used for underway embarkation and disembarkation of
personnel. A survival suit (as pictured to the right) is a full-body single-piece coverall
designed to provide thermal protection to personnel immersed in water. A person
at sea should be able to don a survival suit in one minute while fully clothed and
without having to remove shoes. All negative responses in the Functional Abilities
Screening section require additional explanation on the Continuation Page.
Sign and date the form in Section VII. Do not write in the “MOC Health
Services Use Only” section. Use the Continuation Page to provide any additional
information. Direct all questions regarding the information required on this form to
the MOC Health Services Medical Officer at MOC-Atlantic (757) 441-6320 or MOCPacific (541) 867-8820.

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 15 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 Office of Marine and Aviation Operations, 1315 East West Hwy, Silver Spring, MD
20910.
PRIVACY ACT STATEMENT
Authorities: Privacy Act of 1974, 5 CFR Part 293, Personnel Records and Part 297, Privacy Procedures for Personnel Records;
Occupational Safety and Health Administration, 29 CFR 1910, Occupational Safety and Health Standards, Health Insurance
Portability and Accountability Act, Pub. L. 104-191.
Purposes: The health services you receive through this program result in the gathering and recording of information that is
personal and confidential. Your employing agency serves as a custodian of your records. Upon termination of employment the
original documents or copies of your records will be transferred to your Employee Medical Folder (EMF) in the agency’s
Employee Medical File System (EMFS). These records are stored as a distinct and separate part of your Official Personnel
Folder. Your records are collected and maintained for a variety of purposes, including:
•
to meet the mandates of law, Executive order, or regulations;
•
to provide data necessary for proper medical evaluations, treatment for the continuity of medical care;
•
to provide an accurate medical history and treatment and/or hazard exposures and health monitoring;
•
to enable the planning for further care;
•
to provide a record of communications among members of the health care team;
•
to provide a legal document describing the health care administered and exposure incidents;
•
to provide a method of evaluating the quality of health care rendered as required by professional standards and
legislative authority;
•
to ensure that all relevant, necessary, accurate, and timely data are available to support any medically-related
employment decisions;
•
to document claims filed with and the decisions reached in OWCP cases;
•
to document employee's reporting of occupational injuries, unhealthy and/or unsafe working conditions;
•
to ensure proper and accurate operation of the agency's employee drug testing program under Executive Order
12564.
Routine Uses: Information is collected to manage medical care and to maintain accurate and current medical records on
employees. Disclosure of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared with
applicable entities related to the purposes described above. Disclosure of this information is also subject to all of the published
routine uses as identified in the Privacy Act System of Records Notice, COMMERCE/NOAA–22, NOAA Health Services
Questionnaire (NHSQ) and Tuberculosis Screening Document (TSD).
Disclosure: Collection of this information is voluntary. If you do not wish to participate in these services, or to provide the
requested information, you are not required to do so. Non-NOAA personnel may decline to provide this information, but the
absence of documented medical clearances may prevent you from being cleared to embark on NOAA vessels or aircraft. For
NOAA personnel choosing to decline the health services required for job-related clearances, the absence of documented
medical clearances in will impact the employer’s authority to permit you to perform certain functions of your position. You
should consult with your supervisor in this matter.