NSF-1429-A Employer Endorsement and Release of Liability

2. Employer Endorsement and Release of Liability

Employer Endorsement

Complete this form and obtain the signature of the Authorized Representative for your Organization as noted by your Organization’s internal processes.

Applicant’s Name: ________________________________________

Position: ________________________________________

The National Science Foundation, as manager of the U.S. Arctic/Antarctic Program, requires all candidates for deployment to the Arctic and/or Antarctica under the auspices of the U.S. Arctic/Antarctic Program to undergo and pass a Physical Qualification (PQ) process. The PQ process is designed to identify personnel that are physically qualified and, for winter-over candidates, psychologically adapted for assignment in the Arctic and/or Antarctica. The PQ process is necessary to identify the presence of any physical or psychological condition that would threaten the health or safety of the candidate 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 the Arctic and/or Antarctica medical facilities or from the Arctic and/or 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. 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.  For these reasons, all documentation is reviewed against a rigorous set of Medical Clearance Criteria that were established and are regularly reviewed by qualified medical personnel with extensive experience with conditions in the Arctic and/or Antarctica. The National Science Foundation’s physical qualification process is outlined at 45 CFR 675.

The above-named applicant has been found “not physically qualified” for deployment to the Arctic and/or Antarctica under the auspices of the U.S. Arctic/Antarctic Program due to not meeting the criteria of the Physical Qualification Guidelines.

The National Science Foundation provides a process whereby eligibility for deployment to the Arctic and/or Antarctica may be reconsidered. In order to be reconsidered, the applicant submits an application consisting of an Applicant Statement, an Applicant Release of Liability, an Employer Endorsement, and an Employer Release of Liability. The National Science Foundation’s subcontracted medical provider reviews the application, provides a medical recommendation, and submits the documentation to the National Science Foundation for reconsideration.

The reconsideration process takes approximately six to eight weeks to complete once the application has been submitted. Be advised that applicants may be required to have further medical examinations or to furnish additional medical documentation in support of their application. Costs incurred as a result of these requirements are not reimbursable by the National Science Foundation and must be borne by the applicant or his/her employing organization. In addition, the employer may find it necessary to hire an alternate at any time during this process in order to ensure it is able to perform its responsibilities in the Arctic and/or Antarctica.

If the National Science Foundation rules favorably on the application, the Medical Clearance Criteria as they pertain to the condition for which the applicant was found to be “not physically qualified” will be waived and the applicant will be authorized to deploy. The National Science Foundation may approve the application subject to certain limitations and restrictions. For example, the applicant could be restricted to certain operating locations or required to undergo monitoring of his/her condition by on-site medical providers. The National Science Foundation’s decision on the application is final.

As the Authorized Organizational Representative, you are asked to review the below Employer Endorsement in support of the above-named individual’s application. If you support the individual’s application and agree to the statements contained therein, initial as indicated and sign the Employer Endorsement and the Employer Release of Liability on behalf of your Organization.

NSF Form 1429-A (APR 2024) Page 1 of 3 Original: Submit with packet Applicant: Retain a copy for your records

OMB CONTROL NUMBER 3145-0177: Expires

___________________________________________, is a candidate for deployment to the Arctic and/or Antarctica under the auspices

[applicant’s name] of the U.S. Arctic/Antarctic Program as an employee of

_______________________________________________________________.

[organization]

We were advised that the applicant is “not physically qualified” for deployment to the Arctic and/or Antarctica. _____

[initial]

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

[initial]

We 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 the applicant 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 The Arctic and/or 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]

We 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]

We 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 his/her assignment may involve complete isolation for up to nine months in groups of four to 200 people. _____

[initial]

We understand that the applicant may be required to have further medical examinations or to furnish additional medical documentation in support of his/her application. _____

[initial]

We agree that we will not seek reimbursement of the costs of further medical examinations or additional medical documentation by the National Science Foundation through contracts, cooperative agreements, or grants funded by the National Science Foundation. _____

[initial]

We understand our responsibility to provide a physically qualified work force and therefore that we may elect to hire an alternate at any time during this process. _____

[initial]

We understand that the National Science Foundation may approve the application subject to certain limitations and restrictions which could affect the applicant’s ability to perform his/her duties. _____

[initial]

We are aware of the potential impacts that the applicant’s deployment may have on our organization, including the potential impact of the applicant being unable to perform his or her job while in the Arctic and/or Antarctica. _____

[initial]

By my signature as the Authorized Organizational Representative, I acknowledge the risks associated with ________________________________________ deploying to the Arctic and/or Antarctica with his/her medical condition, and I

[applicant’s name] support his/her Application for Waiver to the National Science Foundation on behalf of the Organization.

NSF Form 1429-A (APR 2024) Page 2 of 3 Original: Submit with packet Applicant: Retain a copy for your records

OMB CONTROL NUMBER 3145-0177: Expires

Employer 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 ________________________________________[applicant], a candidate for employment in the Arctic and/or Antarctica with _______________________________________________________[organization], was found to be “not physically qualified” and thereby authorizing his/her deployment under the auspices of the U.S. Arctic/Antarctic Program, for and on behalf of the Organization, we 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.

_____________________________________________________________ ___________________________________________________________________________

Organization Print Title, Authorized Organizational Representative

_____________________________________________________________ ___________________________________________________________________________

Print Name, Authorized Organizational Representative Authorized Organizational Representative Signature Date

NSF Form 1429-A (APR 2024) Page 3 of 3 Original: Submit with packet Applicant: Retain a copy for your records

OMB CONTROL NUMBER 3145-0177: Expires