NSF-1428-A Applicant Statement and Release of Liability

1. Applicant Statement and Release of Liability

Applicant Statement

I, _____________________________________________, am a candidate for deployment to the Arctic and/or Antarctica under the

[name] auspices of the U.S. Arctic/Antarctic Program as a _____________________________________________ OR under ___________________________________________.

[position/company] [grant number]

I was advised that I am not physically qualified for deployment to the Arctic and/or Antarctica.

I am aware that the Physical Qualification (PQ) process is designed to identify personnel who are physically qualified and, for winter-over candidates, psychologically adapted for assignment in the Arctic and /or Antarctica. _____

[initial]

I understand that the PQ process is necessary to identify the presence of any physical or psychological condition that would threaten the health or safety of myself or of other U.S. Arctic/Antarctic Program participants, that could not be effectively treated by the limited medical care capabilities in the Arctic and/or Antarctica (in addition, transportation to Antarctic medical facilities or from Antarctica to higher level health care facilities may be limited), or that otherwise pose a risk that would jeopardize accomplishment of U.S. Arctic/Antarctic Program objectives. _____

[initial]

I understand that also important during any season, summer or winter, are the costs of lost productivity and the diversion of limited resources that results when deployed personnel are unable to perform their assigned function.  _____

[initial]

I understand that medical care capabilities may be quite distant from work locations and research sites; that work may be required at terrestrial elevations as high as 12,000 feet (3,600 meters); that ambient temperatures may reach

-123 degrees Fahrenheit (-86 degrees Celsius) or lower; that my assignment may involve complete isolation for up to nine months in groups of four to 200 people. _____

[initial]

I understand that I may be required to have further medical examinations or to furnish additional medical documentation in support of my Application for Reconsideration. _____

[initial]

I understand that I will not be reimbursed for the cost of any additional examinations or documentation. _____

[initial]

I understand that my employer has a responsibility to provide a physically qualified work force and therefore it may elect to hire an alternate at any time during this process. _____

[initial]

In the event that the National Science Foundation approves my application subject to certain limitations and restrictions, I agree that if I choose to deploy I will abide by any limitations and restrictions imposed by the National Science Foundation. _____

[initial]

I understand that the National Science Foundation’s decision on my Application for Waiver is final. _____

[initial]

NSF Form 1428-A Page 1 of 2 (APR 2024) Please retain a copy for your records

OMB CONTROL NUMBER 3145-0177: Expires

Applicant Release of Liability

For and in consideration of the National Science Foundation waiving the Medical Clearance Criteria as they pertain to a condition for which I, _________________________[applicant], a candidate for employment in the Arctic and/or Antarctica with _________________________[organization], was found to be “not physically qualified” and thereby authorizing my deployment under the auspices of the U.S. Arctic/Antarctic Program, for and on behalf of myself, my personal representatives, heirs and assigns, hereby release and discharge the U.S., its agents, servants and employees, including but not limited to the National Science Foundation, the Department of Defense and its agencies, agents, servants or employees, whether military or civilian and, where applicable, the Antarctic Support Contractor, its subcontractors, agents, servants, and employees from any and all claims for property damage, personal illness or injury, or death resulting directly or indirectly from waiver of the Medical Clearance Criteria and authorization to deploy.

_______________________________________ ________________________________________________________________

Printed Name Signature Date

NSF Form 1428-A Page 2 of 2 (APR 2024) Please retain a copy for your records

OMB CONTROL NUMBER 3145-0177: Expires