Physical Qualification Packet Checklist and Packet Order

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Ready
Check

Packet
Order
1.
2.
3.
4.
5.
6.
7.
8.
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10.
11.

12.

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14.
15.
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18.
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20.
21.

PQ Packet Checklist and Packet Order
Medical Tests and Packet Order
Items/Notes
Physical Qualification (PQ) Overview (x1 signature)
Electronic Health Record - Registration Form (for Epic entry)
Authorization to Request Protected Health Information/Authorization to Release Information in the Event of a Medical
Emergency (x3 signatures)
Request for Individual Access to Records Protected under the Privacy Act
Health Information Exchange (HIE) Opt-In/Out Request (x1 signature)
Acknowledgment of Receipt of UCHealth Notice of Privacy Practices (signature/date)
Consent to Service
Medical History Form
Arctic Physical Examination
a. If under 45 yrs. only every other year unless modified by medical/nursing direction for prior NPQ, medevac,
MAM, or complicated medical history.
Any MD Notes
Immunizations: REQUIRED immunizations that you must provide written documentation for:
a. Seasonal Influenza (exception for Arctic participants deploying in late spring/summer)
b. Measles (if not immune)
c. COVID-19 (CDC up-to-date recommendations) – Must complete CDC up-to-date recommendations for
vaccination at least 14 days prior to deployment.
d. TDaP (Tetanus, Diphtheria, and Pertussis)
Lab Test Results (required for all participants)
a. Complete Blood Count with Differential
b. Blood Chemistries (Sodium, Potassium, Chloride, Glucose, Creatinine, GFR/BUN, Calcium)
c. Hepatic Panel (Alkaline Phosphatase, Total Bilirubin, AST (SGOT), ALT (SGPT))
d. Lipid Panel (Cholesterol, HDL, LDL, Triglycerides)
e. Hepatitis B core total antibody (Anti-HBc)
f.
Hepatitis C antibody (Anti-HCV)
g. RPR (syphilis)
h. Blood Type (ABO and RH)- required annually per American Blood Bank policies
i.
Quantiferon TB
j.
MMR Titer
k. HgA1c: If has history of diabetes or glucose greater than 100
l.
HIV: Required if you elected YES for volunteering for the walking blood bank (United States Arctic Program
Deployment Consent/Authorization Documents -pg. 32
a. TSH: History of hyper/hypothyroidism.
b. Guaiac Stool test (If age 50+)
Twelve-lead EKG tracing or rhythm strip
a. All new participants; then, age 40-49 every 5 yrs; then, age 50+ annually
Exercise Stress Test (Criteria as noted in Appendix 1)
a. Summer Participant: required only if FHR score greater than 20%.
Pulmonary Function Test, pre/post bronchodilator
a. History of asthma, emphysema, or COPD OR occupational PFT (spirometry for work)
Mammogram (females) (radiology)
a. Age 40+ every 2 years
Chest X-Ray
a. Per TB protocol for positive PPD/ Quantiferon; or symptomatic pulmonary disease
Submit report only, not actual films
Low-dose CT (screening for lung cancer)
a. Screen participants at high-risk for lung cancer: Age 55-80, AND at least 30 pack-yr history, AND current
smoker or quit less than 15 years ago
Arctic Dental Examination
United States Arctic Program Deployment Consent/Authorization Documents
Authorization for Treatment of Field-Team Member/Participant Under 18-Years of Age

Arctic PQ Packet
REVISED: 01/2024

Page in Packet
Page 2
Page 3
Page 4 – 11
Page 12– 16
Page 17
Page 18
Page 19
Page 20 – 24
Page 27 & 28, bring
Pages to Doctor
appointment

Page 29 & 30
Page 31 & 32
Page 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Physical Qualification (PQ) Overview
University of Colorado (CU) Polar Medicine
Congratulations on your prospective candidacy to support NSF Arctic north programs for the 2024
season! Due to the unique conditions and remote location associated with deployment, the NSF
requires candidates to complete a process to physically qualify (PQ) for that deployment. This is an
annual medical screening that includes:
1)
2)
3)
4)

a visit to a lab to complete required screening studies including blood work
a visit to a medical provider (MD, DO, NP, PA) for a physical exam and history
a visit to a dentist to include x-rays
Submission of the completed packet with requested documentation attached

The CU Polar Medicine team will review the submitted materials to ensure all necessary
documentation is included. A medical provider will review the medical information to assign a
designation of “Physically Qualified” (PQ) indicating that deployment can proceed or “Not Physically
Qualified” (NPQ) indicating that deployment will be rescinded. If a designation of NPQ is assigned, the
NSF has a waiver process that may be considered.
Full Disclosure: In the interest of the health and well-being of both yourself and the other program
members, please answer the questions honestly and completely on this health form. A “Yes” answer
does not automatically cancel your qualification. If we have a question regarding your capacity to
successfully participate, we will contact you to discuss it. Failure to disclose a health condition that
becomes relevant while on your deployment may result in a costly evacuation, disruption to
research and other arctic activities, or a fatal event.
I realize that failure to disclose information could result in serious harm to myself and fellow program
members. I agree to inform CU Polar Medicine, Battelle-ARO, and the National Science Foundation
should there be any change in my health status prior to the start of the deployment. Based on the
deployment description, and what I know or suspect about my physical and psychological health, I am
fully capable of participating in this arctic deployment.
By my signature, I confirm that the information provided on this form will be an accurate and complete
representation of my health history.
Participant’s Signature
Date
You are not approved to deploy until this health form has been reviewed and approved by CU
Polar Medicine personnel.
Thank you for your careful attention to completion of ALL forms within this document and timely
submission to the CU Polar Medicine. If you have any questions concerns, please contact the PQ
team promptly at [email protected].

Arctic PQ Packet

Page 2 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Electronic Health Record- Registration Form
**Of note: Information on this form is required for the creation of your electronic
health record and can be helpful for us to be able to assist you best if an
emergency arises during deployment.
First Name:

Last Name:

MI:

Deployment Location:

Prospective Date of Deployment:

Social Security Number:

Sex:

Date of Birth:

Age:

Male

Female

Preferred Pronouns:
*** Social Security Number is used as a measure to ensure that medical staff has the correct medical record, but is
not required. If you would prefer, please call our admin, Kellie Schiller, at 802-275-6367 and she can take down
your SS# over the phone.

Address:
City:

State:

Zip Code:

Phone Number:

Email Address:

Arctic PQ Packet

Page 3 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Authorization to Request Protected Health Information

*** Note: This form gives consent for our Arctic PQ team to reach out to your providers to request additional
information, such as, work-up, supporting medical records, a letter of support, or more insight from your provider
regarding a medical condition, ONLY WHEN NEEDED. We ask all patients beforehand if we can contact their
provider.

Patient Name:

Birth Date:

Address:
City/State:

ZIP:

Phone Number:

I authorized release:
FROM: Primary Care Clinic/Medical Facility

TO the following Medical facility

Name:

Name: CU Polar Medicine

Facility:

Facility: University of Colorado, Anschutz Medical
Campus

Address:

Address:
CU Polar Medicine
Mail Stop C328
12631 E 17th Ave
Aurora, CO 80045

Phone:

Phone: 802-275-6367

FAX:

FAX: 303-724-5649

Date of service range (month/year)*** From: _____________ To: ___________________
*** (Put date range from date of doctors appointment to end of deployment)
Clinic/Progress notes

Laboratory results

Complete (All records, notes, meds, flowsheets, etc).

Mental health treatment**

Discharge summary

Operative note

Drug/Alcohol treatment**

Radiology reports

Emergency room report

Sickle cell information**

Facesheet

STD/Communicable disease**

Genetic information**

Immunization record

History & Physical

HIV/AIDS information**

Visit record (includes emergency room records, provider
notes/reports, health date, medical history, medicine and allergy
lists, test results; does not include images)

Visit summary (includes provider notes/reports, test results;
does not include images)

Other: __________________________________________________________________________________________

** I hereby consent to disclose the above bolded specialized information.
____________________________________________________________________________
Patient’s signature required.

Arctic PQ Packet

Page 4 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

1. I authorize the release of my medical record, including photographs.
2. This authorization is voluntary, and the disclosure is made at my request.
3. If the organization authorized to receive the information is not a health plan or health care
provider, the released information may no longer be protected by federal privacy regulations.
4. Multiple requests are authorized if the purpose of the request remains the same.
5. I have a right to revoke this authorization at any time, and if I revoke this authorization, I must
do so in writing and present the written revocation to the department that I have authorized to
release the information. Any revocation will not apply to information that has already been
released in response to this authorization.
6. I need not sign this form to ensure health care treatment.
7. Potential for redisclosure: Your health information disclosed according to this authorization will
no longer be protected by the federal privacy law (known as "HIPAA"), and the recipient of the
information may potentially redisclose it.
I request this authorization to expire on
below and covers only treatment for the date(s) specified above.

or 180 days from the date signed

IMPORTANT WARNING: The documents accompanying this message are intended for the use of the
person or entity to which this message is addressed. These documents may contain information that is
privileged and confidential, the disclosure of which is governed by applicable law. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law. If you are the employee or agent responsible to deliver this information to the intended
recipient, you are hereby notified that any dissemination, distribution, or copying of this information is
STRICTLY PROHIBITED.
_____________________________________________________
Signature of patient or legal representative

__________________
Date

Authorization to Release Information in the Event of a Medical Emergency
In the event of a medical emergency, I authorize my information to be released to the National Science
Foundation and/or Battelle Arctic Research Operations teammates only for the purposes of facilitating
urgent/emergent medical care and/or evacuation. Information released will be limited to the minimum
data required to ensure emergent medical care or emergency medical evacuation and will be limited
only to select teammates providing clinical care and/or those required to coordinate
evacuation/emergency medical care. I reserve the right to revoke this permission at any time.
_____________________________________________________
Signature of patient or legal representative

Arctic PQ Packet

__________________
Date

Page 5 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Authorization to Request Protected Health Information

*** Note: This form gives consent for our Arctic PQ team to discuss/provide your medical
information with your primary care provider. In the event of an emergency during deployment,
this would allow us to update your primary care provider, if needed.
Patient Name:

Birth Date:

Address:
City/State:

ZIP:

Phone Number:

I authorized release:
FROM: Medical Facility

TO: Primary Care Clinic/Medical Facility

Name: CU Polar Medicine

Name:

Facility: University of Colorado, Anschutz Medical
Campus

Facility:

Address:

Address:

CU Polar Medicine
Mail Stop C328
12631 E 17th Ave
Aurora, CO 80045
Phone: 802-275-6367
FAX:

303-724-5649

Phone:
FAX:

Date of service range (month/year)*** From: _____________ To: ___________________
*** (Put date range from date of doctors appointment to end of deployment)
Clinic/Progress notes

Laboratory results

Complete (All records, notes, meds, flowsheets, etc).

Mental health treatment**

Discharge summary

Operative note

Drug/Alcohol treatment**

Radiology reports

Emergency room report

Sickle cell information**

Facesheet

STD/Communicable disease**

Genetic information**

Immunization record

History & Physical

HIV/AIDS information**

Visit record (includes emergency room records, provider
notes/reports, health date, medical history, medicine and allergy
lists, test results; does not include images)

Visit summary (includes provider notes/reports, test results;
does not include images)

Other: __________________________________________________________________________________________

** I hereby consent to disclose the above bolded specialized information.
____________________________________________________________________________
Patient’s signature required.

Arctic PQ Packet

Page 6 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

1. I authorize the release of my medical record, including photographs.
2. This authorization is voluntary, and the disclosure is made at my request.
3. If the organization authorized to receive the information is not a health plan or health care
provider, the released information may no longer be protected by federal privacy regulations.
4. Multiple requests are authorized if the purpose of the request remains the same.
5. I have a right to revoke this authorization at any time, and if I revoke this authorization, I must
do so in writing and present the written revocation to the department that I have authorized to
release the information. Any revocation will not apply to information that has already been
released in response to this authorization.
6. I need not sign this form to ensure health care treatment.
7. Potential for redisclosure: Your health information disclosed according to this authorization will
no longer be protected by the federal privacy law (known as "HIPAA"), and the recipient of the
information may potentially redisclose it.
I request this authorization to expire on
below and covers only treatment for the date(s) specified above.

or 180 days from the date signed

IMPORTANT WARNING: The documents accompanying this message are intended for the use of the
person or entity to which this message is addressed. These documents may contain information that is
privileged and confidential, the disclosure of which is governed by applicable law. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law. If you are the employee or agent responsible to deliver this information to the intended
recipient, you are hereby notified that any dissemination, distribution, or copying of this information is
STRICTLY PROHIBITED.
_____________________________________________________
Signature of patient or legal representative

Arctic PQ Packet

__________________
Date

Page 7 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Authorization to Request Protected Health Information

*** Note: This form gives consent for CU Polar Medicine to share records to UTMB, such as in
the case of PQ Transfers.
Patient Name:

Birth Date:

Address:
City/State:

ZIP:

Phone Number:

I authorized release:
FROM: Medical Facility

TO the following Medical facility

Name: CU Polar Medicine

Name: Center for Polar Medical Operations

Facility: University of Colorado, Anschutz Medical
Campus

Facility: University of Texas Medical Branch

Address:

Address:

CU Polar Medicine
Mail Stop C328
12631 E 17th Ave
Aurora, CO 80045

Levin Hall 5th Floor

Phone: 802-275-6367

Phone: (855) 300-9704

FAX:

303-724-5649

Date of service range (month/year)***

301 University Blvd
Galveston, TX 77555-1004

FAX:

From: _____________

To: ___________________

*** (Put date range from date of last submitted PQ packet with CU (if applicable) or doctors appointment, to end of deployment)
Clinic/Progress notes

Laboratory results

Complete (All records, notes, meds, flowsheets, etc).

Mental health treatment**

Discharge summary

Operative note

Drug/Alcohol treatment**

Radiology reports

Emergency room report

Sickle cell information**

Facesheet

STD/Communicable disease**

Genetic information**

Immunization record

History & Physical

HIV/AIDS information**

Visit record (includes emergency room records, provider
notes/reports, health date, medical history, medicine and allergy
lists, test results; does not include images)

Visit summary (includes provider notes/reports, test results;
does not include images)

Other: __________________________________________________________________________________________

** I hereby consent to disclose the above bolded specialized information.
____________________________________________________________________________
Patient’s signature required.

Arctic PQ Packet

Page 8 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

1. I authorize the release of my medical record, including photographs.
2. This authorization is voluntary, and the disclosure is made at my request.
3. If the organization authorized to receive the information is not a health plan or health care
provider, the released information may no longer be protected by federal privacy regulations.
4. Multiple requests are authorized if the purpose of the request remains the same.
5. I have a right to revoke this authorization at any time, and if I revoke this authorization, I must
do so in writing and present the written revocation to the department that I have authorized to
release the information. Any revocation will not apply to information that has already been
released in response to this authorization.
6. I need not sign this form to ensure health care treatment.
7. Potential for redisclosure: Your health information disclosed according to this authorization will
no longer be protected by the federal privacy law (known as "HIPAA"), and the recipient of the
information may potentially redisclose it.
I request this authorization to expire on
below and covers only treatment for the date(s) specified above.

or 180 days from the date signed

IMPORTANT WARNING: The documents accompanying this message are intended for the use of the
person or entity to which this message is addressed. These documents may contain information that is
privileged and confidential, the disclosure of which is governed by applicable law. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law. If you are the employee or agent responsible to deliver this information to the intended
recipient, you are hereby notified that any dissemination, distribution, or copying of this information is
STRICTLY PROHIBITED.
_____________________________________________________
Signature of patient or legal representative

Arctic PQ Packet

__________________
Date

Page 9 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Authorization to Request Protected Health Information

*** Note: This form gives consent for UTMB to share records to CU Polar Medicine, such as in
the case of PQ Transfers.
Patient Name:

Birth Date:

Address:
City/State:

ZIP:

Phone Number:

I authorized release:
FROM: Medical Facility

TO the following Medical facility

Name: Center for Polar Medical Operations

Name:
Name: CU Polar Medicine

Facility: University of Texas Medical Branch

Facility:
Facility: University of Colorado, Anschutz Medical
Campus

Address:

Address:

Galveston, TX 77555-1004

CU Polar Medicine
Mail Stop C328
12631 E 17th Ave
Aurora, CO 80045

Phone: (855) 300-9704

Phone: 802-275-6367
Phone:

FAX:

FAX: 303-724-5649

Levin Hall 5th Floor
301 University Blvd

Date of service range (month/year)

From: _____________

To: ___________________

*** (Put date range from date of last submitted PQ packet with UTMB (if applicable) or doctors appointment, to end of deployment)
Clinic/Progress notes

Laboratory results

Complete (All records, notes, meds, flowsheets, etc).

Mental health treatment**

Discharge summary

Operative note

Drug/Alcohol treatment**

Radiology reports

Emergency room report

Sickle cell information**

Facesheet

STD/Communicable disease**

Genetic information**

Immunization record

History & Physical

HIV/AIDS information**

Visit record (includes emergency room records, provider
notes/reports, health date, medical history, medicine and allergy
lists, test results; does not include images)

Visit summary (includes provider notes/reports, test results;
does not include images)

Other: __________________________________________________________________________________________

** I hereby consent to disclose the above bolded specialized information.
____________________________________________________________________________
Patient’s signature required.

Arctic PQ Packet

Page 10 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

1. I authorize the release of my medical record, including photographs.
2. This authorization is voluntary, and the disclosure is made at my request.
3. If the organization authorized to receive the information is not a health plan or health care
provider, the released information may no longer be protected by federal privacy regulations.
4. Multiple requests are authorized if the purpose of the request remains the same.
5. I have a right to revoke this authorization at any time, and if I revoke this authorization, I must
do so in writing and present the written revocation to the department that I have authorized to
release the information. Any revocation will not apply to information that has already been
released in response to this authorization.
6. I need not sign this form to ensure health care treatment.
7. Potential for redisclosure: Your health information disclosed according to this authorization will
no longer be protected by the federal privacy law (known as "HIPAA"), and the recipient of the
information may potentially redisclose it.
I request this authorization to expire on
below and covers only treatment for the date(s) specified above.

or 180 days from the date signed

IMPORTANT WARNING: The documents accompanying this message are intended for the use of the
person or entity to which this message is addressed. These documents may contain information that is
privileged and confidential, the disclosure of which is governed by applicable law. Unauthorized redisclosure or failure to maintain confidentiality could subject you to penalties described in federal and
state law. If you are the employee or agent responsible to deliver this information to the intended
recipient, you are hereby notified that any dissemination, distribution, or copying of this information is
STRICTLY PROHIBITED.
_____________________________________________________
Signature of patient or legal representative

Arctic PQ Packet

__________________
Date

Page 11 of 33

NATIONAL SCIENCE FOUNDATION
2415 EISENHOWER AVENUE
ALEXANDRIA, VIRGINIA 22314

INFORMATION FOR INDIVIDUALS MAKING REQUESTS TO THE
OFFICE OF POLAR PROGRAMS FOR RECORDS UNDER THE PRIVACY ACT OF 1974
To request information collected in the course of NSF’s medical screening or care provided while
deployed to the polar regions, please complete the Request for Individual Access to Records to make
an official records request verifying the identity of the requestor. Due to the COVID-19 pandemic
and the full-time telework posture of NSF, NSF is allowing submission of this form
electronically via email as long as the identity of the requestor is consistent with the identity on
the records being requested. Please send all requests password protected then in a separate
email provide the password. Upon receipt of the official request, NSF expects to respond within
20 business days. Please note that NSF cannot provide copies of X-ray films. Medical records are
not kept indefinitely and some older records may not be available.
NOTE: If you are providing consent and authorizing the agency to disclose your records to another
person or entity, the Consent for Disclosure form will need to be submitted. Please send all requests
password protected then in a separate email provide the password.
INSTRUCTIONS
1) Enter the requestor’s name, physical address, email and phone number.
2) Provide specific information detailing the records requested and the time period covered by
the request.
3) Provide the record requestor’s name, address, phone number and email. The phone number
and email will only be used in the event that NSF has questions regarding the request.
4) Provide the physical address where NSF will send the records. Records cannot be sent to a
Post Office (P.O.) box. If sending the records to a third party (e.g. a physician’s office),
provide the recipient’s name and address. A specific person must be named to receive the
documents.
5) Verify under penalty of perjury by signing the form at the bottom, or notarize the form
provided, to ensure this is a true and correct request.
Point of Contact:
Elicia Liles
Office of Polar Programs
National Science Foundation
2415 Eisenhower Avenue
Alexandria, VA 22314
Email: [email protected]
Phone: 571-215-4420
Requests may also be sent to NSF’s Office of the General Counsel. More information is available
on NSF’s FOIA and Privacy Act website: https://www.nsf.gov/policies/foia.jsp.

Privacy Act Request, Office of Polar Programs

Arctic PQ Packet

Updated 3/2021

Page 12 of 33

NATIONAL SCIENCE FOUNDATION
Request for Individual Access to Records Protected under the Privacy Act
If you are seeking access to your records, please provide the information below. This form may
also be used if you are the parent seeking access to the records of a minor or the legal guardian
seeking access to the records of an incompetent.
Information Required for Identity-Proofing and Authentication
This information is required for the agency to verify your identity.
Full Name:
Address:
Email:

Phone Number:

If Applicable: Information for Request by Parent or Legal Guardian
Name of Record Subject:
Relationship to Subject:

Additional Information Required to Locate the Record(s)
Record Type (select all that apply):
✔ Medical Treatment
If other, please specify:

✔ Physical Therapy

✔ Other

Dental Records

Record dates beginning on:

.

ending on:

Contact Information
Physical Address for Receiving Records:
CU Polar Medicine, Mail Stop C328, 12631 E 17th Ave, Aurora, CO 80045
Phone Number: 802-275-6367

Arctic PQ Packet

Email Address: [email protected]

Page 13 of 33

In accordance with 28 U.S.C. § 1746, I elect to use the following statement in lieu of
notarization:
I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct, and that I am the person named above and requesting access
to my records [, or records that I am entitled to request as the parent of a minor or the legal
guardian of an incompetent], and I understand that any falsification of this statement is
punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more
than five years, or both, and that requesting or obtaining any record(s) under false
pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more
than $5,000.
Signature:

Date:
Privacy Act Statement

In accordance with the National Science Foundation’s Privacy Act implementation rules,
personal information sufficient to identify the individuals requesting access to records
under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this
solicitation is to ensure that the records of individuals who are the subject of the National
Science Foundation systems of records are not wrongfully disclosed by the National
Science Foundation. Requests will not be processed if this information is not furnished.
False information on this form may subject the requester to criminal penalties under 18
U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3).

Arctic PQ Packet

Page 14 of 33

NATIONAL SCIENCE FOUNDATION
Request for Individual Access to Records Protected under the Privacy Act
If you are seeking access to your records, please provide the information below. This form may
also be used if you are the parent seeking access to the records of a minor or the legal guardian
seeking access to the records of an incompetent.
Information Required for Identity-Proofing and Authentication
This information is required for the agency to verify your identity.
Full Name:
Address:
Email:

Phone Number:

If Applicable: Information for Request by Parent or Legal Guardian
Name of Record Subject:
Relationship to Subject:

Additional Information Required to Locate the Record(s)
Record Type (select all that apply):
✔ Medical Treatment

✔ Physical Therapy

✔ Other

If other, please specify: Dental Records
Record dates beginning on:

.

ending on:
Contact Information

Physical Address for Receiving Records:
Center for Polar Medical Operations
University of Texas Medical Branch
Levin Hall 5th Floor, 301 University Blvd
Galveston, TX 77555-1004

Phone Number: 855-300-9704

Arctic PQ Packet

Email Address: [email protected]

Page 15 of 33

In accordance with 28 U.S.C. § 1746, I elect to use the following statement in lieu of
notarization:
I declare under penalty of perjury under the laws of the United States of America that the
foregoing is true and correct, and that I am the person named above and requesting access
to my records [, or records that I am entitled to request as the parent of a minor or the legal
guardian of an incompetent], and I understand that any falsification of this statement is
punishable under the provisions of 18 U.S.C. § 1001 by a fine, imprisonment of not more
than five years, or both, and that requesting or obtaining any record(s) under false
pretenses is punishable under the provisions of 5 U.S.C. § 552a(i)(3) by a fine of not more
than $5,000.
Signature:

Date:
Privacy Act Statement

In accordance with the National Science Foundation’s Privacy Act implementation rules,
personal information sufficient to identify the individuals requesting access to records
under the Privacy Act of 1974, 5 U.S.C. § 552a, is required. The purpose of this
solicitation is to ensure that the records of individuals who are the subject of the National
Science Foundation systems of records are not wrongfully disclosed by the National
Science Foundation. Requests will not be processed if this information is not furnished.
False information on this form may subject the requester to criminal penalties under 18
U.S.C. § 1001 and/or 5 U.S.C. § 552a(i)(3).

Arctic PQ Packet

Page 16 of 33

CU Polar Medicine
Mail Stop C328
12631 E. 17th Avenue, Room 2509 | Aurora, CO 80045
FAX: 303-724-5649 | [email protected]
coloradoWM.org

Please note that opting in or out of the Health Information Exchange (HIE) will not influence your PQ
decision, nor will it delay your PQ decision. Opt-in allows your primary medical records to be reviewed
electronically by the PQ team and allows your primary medical team to review your PQ paperwork, if
your clinic participates in EPIC sharing.

Health Information Exchange (HIE) Opt-In/Out Request
UCHealth Clinics and aligned medical facilities participates in the electronic exchange of
protected health information (“PHI”) with other health care providers and health insurance
plans through approved health information exchange organizations. Through UCHealth’s
participation, PHI may be accessed by other providers and health insurance plans or other
permitted recipients of PHI, as permitted by law, for treatment, payment, and health care
operations purposes. These health information exchanges maintain safeguards to protect the
privacy of your PHI. You are able to opt-out of having your PHI accessed on these exchanges.
In Colorado, UCHealth clinics and aligned medical facilities participates in the Colorado
Regional Health Information Organization (CORHIO).
I understand that by OPTING IN I am requesting that my health information is viewable
through the health information exchange systems listed above.
•
•

A separate form must be filled out for each family member requesting to opt back
in to the HIE system.
All fields are required for the form to be processed.

I understand that by OPTING OUT I am requesting that my health information is not viewable
through the health information exchange systems listed above.
Select here if you want to Opt In or Opt Out:
Opt In
Opt Out
_____________________________________________________
Signature of patient or legal representative

Arctic PQ Packet

__________________
Date

Page 17 of 33

_uchealth_
Acknowledgment of Receipt of
UCHealth Notice of Privacy Practices
This consent applies to all hospitals, physician offices, and other facilities that are part of University of Colorado Health
("UCHealth"), including to UCHealth Broomfield Hospital, UCHealth Grandview Hospital, Longs Peak Hospital, Medical
Center of the Rockies, Poudre Valley Hospital, UCH-MHS (Memorial Hospital), UCHealth Greeley Hospital, UCHealth
Highlands Ranch Hospital, UCHealth Pikes Peak Regional Hospital, University of Colorado Hospital Authority, UCHealth
Yampa Valley Medical Center, UCHealth Medical Group, UCHealth Imaging Services, LLC, UCHealth Partners (including
UCHealth Emergency Rooms) and UCHealth Ambulatory Surgery Centers (each a "Facility"), including all health care
providers at those facilities, some of whom are employed by the University of Colorado.
By signing this document, I acknowledge that I have received a copy of the Notice of Privacy Practices for UCHealth,
which is included in your Arctic PQ Information document.
DO NOT SIGN UNLESS YOU HAVE READ AND THOROUGHLY UNDERSTAND THIS FORM.

N/A

Name of patient (printed)

Name of witness (printed)

Signature of patient or legally authorized representative

Signature of witness

N/A
Self

N/A

Relationship to patient

Date

Date

N/A

_____ (Initials)

N/A
Time

Time

Directed by patient/legal representative to sign on his/her behalf after reading document to him/her.

N/A

Reason for directed signature ___________________________________

N/A

N/A

Interpretation: Informed consent discussion interpreted for patient/representative by (name)_ _ __ _ __ (date/time)______ _

Page 18 of 33

uchealtb

�

�

Consent to Service

Additionally, some health care providers at the Facility are considered federal employees. Federal sovereign immunity
generally bars claims against federal employees, however, in certain circumstances, the Federal Tort Claims Act (FTCA),
which provides a limited waiver of sovereign immunity, may apply. Under the FTCA, an administrative claim must be filed
with the appropriate military agency within two years of the incident.
By signing this agreement below, I acknowledge that:
•

I have read this document and understand its contents.

•

I agree to this Agreement

•

I agree that I have provided correct and accurate information about the patient (including current address, telephone
number, email address, insurance information, and medical history) for health care.

•

I understand that I have the right to have a copy of this Agreement.

•

The law of the State of Colorado will apply to this Agreement.

•

In any legal action brought under this Agreement, I waive my right to trial by jury.

•

I understand that no person working at Facility is allowed to change or erase any part of this document. Changes or
anything that was added or deleted will not change the original (first) agreement, but that I've had an opportunity to
ask questions about this Agreement and have received answers to such questions. I enter into this Agreement freely,
knowingly, and voluntarily.

N/A
Name of patient (printed)

Name of witness (printed)

Signature of patient or legally authorized representative

Signature of witness

N/A
Self

N/A

Relationship to patient (if applicable)

Date

Date

Time

N/A

____ (Initial)

N/A
Time

□ a.m. □ p.m.

□ a.m. □ p.m.

Directed by Patient/Legal Representative to sign on patient's behalf, after reading document to him/her.

N/A
Reason for directed signature---------------------------------Discussion interpreted by:

N/A

N/A

Language ______ _ ________Operator# or Interpreter name _ _ _______________ _

Page 19 of 33

PARTICIPANT NAME

ARCTIC

MEDICAL HISTORY

The PARTICIPANT COMPLETES this Medical Historv form prior to any exam
Arctic Medical Staff Use Only

Date:

□

D WinterPQ

OSummerPQ

Medical Condition(s):

NPQ

Reviewed by:
Restrictions and Follow-up:

Date:

Reason for NPQ:

I

I

CONTACT INFORMATION (INCLUDE AREA CODES):
Name last, frrst, middle (must match official ID):

I

Nickname:
Street Address:

Age:

Birthdate:

Maiden Name:

(MM/DD/YYYY)

I□\

□M

Previous Name or Other Legal Name:
E-Mail:

City:

State:

Zip:

Country:

Day Telephone:

Evening Telephone:

Mobile:

Fax:

EMERGENCY POINT OF CONTACT:
Address:

Name:
Phone Number:

DEPLOYMENT INFORMATION
Job Title:

Estimated Deployment Dates:

Prior Polar Deployment (Arctic or Antarctic)?

From:

Location:

(MMNYYY)

To:

Affiliation:

□ NSF □ Science Event

To:

□ Technical Event

□ Other

Company Name
Proposed Arctic Season

(MM/YYYY)

From:

Dates

Worksite

D Summer (Mar-Aug)

OSummit Station

D Winter (Sept-Feb)

D Field Camp

□

Other (specify):

Dvessel

(dates)

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 20 of 33

MEDICAL HISTORY FORM

PARTICIPANT NAME

ARCTIC

MEDICAL HISTORY
CURRENT MEDICATIONS - (Check box if None)
CU
Frequency
Name
Dose

Name

Dose

Frequency

DRUG ALLERGIES - (Check box if None)

FOOD ALLERGIES - (Check box if None)

Name

Name

Type of Reaction

Type of Reaction

PAST HOSPITALIZATIONS - (Check box if None)
Condition

Date

(YYYY)

Condition

Date

(YYYY)

(YYYY)

Condition

Date

(YYYY)

PAST SURGERIES - (Check box if None)
Condition

Date

MEDICAL TESTING / PROCEDURES IN PREVIOUS 3 YEARS - (Check box if None)
Type (specify body location)
MRI
CT
Ultrasound
Angiogram
Biopsy
Other:

Date

VACCINATION HISTORY
Most recent vaccination Date
Influenza (Current Deployment Season)
DT/Tdap
MMR
Hepatitis A
Hepatitis B
LIFESTYLE
Tobacco

(YYYY)

Describe reason for test procedure and result:

(YYYY)

Bacillus - Calmette (BCG) Vaccine
(Given in childhood in countries with
high rates of TB)

Yes

No

Describe: Packs/Day

Yes

Total yrs.

No

Year last

Do you currently use tobacco products?
Have you used tobacco products
in the past?
NSF Form 1700 (rev October 2017)
OMB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 21 of 33

MEDICAL HISTORY FORM

ARCTIC
Alcohol

PARTICIPANT NAME
Yes

Do you drink alcohol?
Have you ever felt you should decrease your
alcohol consumption?
Have you ever received a DUI, DWAI or
court ordered treatment for alcohol?
Have you been diagnosed as an alcoholic?
Exercise and conditionin2

Do you have a regular exercise program?
Have you had a cardiovascular stress test?

I I

No

I

□ □
□ □
□ □
□ □
□ □

Yes

No

If abstinent, please enter date of your last
alcoholic beverage (or NONE):

(YYYY or NONE)

Describe frequency and type ofalcohol:
Describe ''yes" answers to alcohol questions:

Describe frequency and type ofexercise :

Date oflast Exercise Stress Test:

(MM/YYYY)

GENERAL MEDICAL fflSTORY

New Government regulations require that you be informed of the following:
"The Genetic Information Nondiscrimination Act of2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information. 'Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or
family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and
genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or
family member receiving assistive reproductive services."
Therefore, you should not forward any information related to your family's medical history and only submit answers to these questions
regarding your own personal/individual history.
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL IDSTORY
1

IA
1B

IC

ID
IE
IF
JG

1H

II

lJ
IK
2

2A
2B
2C

Condition
Neurolo2y

Cerebrovascular accident (CVA)
Concussion
Dizziness/Loss of Consciousness
Headaches (Migraine)
Headaches (Other)
Multiple sclerosis
Peripheral neuropathy
Seizures
Transientischemic attack (TIA)
Traumatic brain injury (TBI)
Other neurological disorder
Cardiolo2y

Angina/chest pain
Atrial fibrillation
Cardiac pacemaker/defibrillator

Yes

No

2D
2E
2F
2G
2H
21
2J
2K
3
3A
3B
3C
3D
3E
3F

Condition

Congestive heart failure
Coronary angioplasty/stent/bypass
Coronary artery disease
Heart murmur/valvular heart disease
Hypertension (hi!!h blood pressure)
Myocardial Infarction (MI)
Supraventricular tachycardia (SVT)
Other cardiac condition
Vascular disease

Abdominal aneurysm
Arterial emboli
Cerebral aneurysm
Deep venous thrombosis (DVT)
Venous stasis ulcers
Other vascular condition

Yes

No

□
□

□
□

□
□

□
□

For all "yes" answers provide details to include line number, age of onset, frequency of event, date of last episode, current medications,
other therapies and current status of the condition.

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 22 of 33

MEDICAL HISTORY FORM

ARCTIC

PARTICIPANT NAME
GENERAL MEDICAL HISTORY

ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT OR PAST MEDICAL HISTORY
Condition
Yes
No
Condition
Yes
Rheumatologic & Autoimmune disease
Irritable bowel syndrome (JBS)
4
81
Pancreatitis
Fibromyalgia
SJ
4A
Osteoarthritis
8K
Peptic ulcer disease
4B
Rheumatoid arthritis
SL
Ulcerative colitis
4C
4D
8M
Systemic Lupus erythematosis
Other gastrointestinal disease
4E
Dermatology
9
Other Rheumatologic/Autoimmune
condition
9A
Dermatitis
9B
Melanoma
Ears, Nose and Throat
5
5A
9C
Psoriasis/Eczema
Hearing impairment
9D
5B
Nosebleeds
Skin cancer
Seasonal Allergies
5C
9E
Other skin condition
10
Ophthamology
Orthopedic
6
6A
Cervical spine injury
Glaucoma
l0A
l0B
Chronic pain
6B
Visual impairment
Other eye condition
Dislocation
l0C
6C
6D
l0D
Fractures
Lasik/restorative surgery
Low back injury
l0E
Pulmonary
7
7A
Altitude sickness
l0F
Orthopedic pins/plates
7B
l0G
Asthma after 10 years of age
Other orthopedic condition
Chronic bronchitis/bronchiectasis
11
7C
Metabolic
7D
llA
Adrenal insufficiency
Chronic obstructive pulmonary disease
llB
Diabetes Type I
Dyspnea (shortness of breath)
7E
Diabetes Type II
llC
Obstructive sleep apnea
7F
llD
7G
Pulmonary embolism
Gout
llE
Positive TB Test/Treatment
Hypercholesterolemia
7H
I IF
Chronic cough (greater than 3 weeks)
Hyperthyroidism
71
llG
Hypothyroidism
Night sweats
7J
llH
Unexplained weight loss
Pituitary insufficiency
7K
Exposed to anyone with known TB
llI
7L
Other hormonal disorder
Other pulmonary condition
12
7M
Gynecology-female
12A
Menstrual period over 30 days ago?
Gastro intestinal disease
8
12B
Date of last PAP smear
8A
Black tarry stools/Blood in stool
Premenstrual syndrome (PMS)
12C
Cholelithiasis (gall stones)
8B
12D
Endometriosis
SC
Crohn's disease
12E
Severe menstrual cramps
Frequent or persistent diarrhea
8D
12F
Gastroesophageal reflux (GERD)
SE
Ovarian cysts
SF
Hemorrhoids
12G
Sexually transmitted disease
12H
Other gynecological conditions
Hepatitis (describe below)
8G
HIV
8H
Hernia
121

□

No

□

For all "yes" answers provide details to include line number, age of onset, frequency of event, date of last episode, current medications,
other therapies and current status of the condition.

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 23 of 33

MEDICAL HISTORY FORM

ARCTIC

13
13A
13B
13C
13D
13E
13F
13G
13H
131
13J
13K
14
14A
14B
14C
14D
14E

PARTICIPANT NAME

GENERAL MEDICAL HISTORY
ANSWER THE FOLLOWING QUESTIONS REGARDING YOUR PRESENT AND PAST MEDICAL HISTORY
Yes
Yes
No
No
Condition
Condition
15
Psychiatric
Hematolo2v/Oncolo!!Y

Addiction
Anxiety/panic attacks
Attention deficit disorder
Bipolar
Depression
Eating disorder (bulimia/anorexia)
Hospitalization for psych condition
Post-traumatic stress disorder
Schizophrenia
Suicidal thoughts or attempts
Other psychiatric condition
Renal disease

Chronic Renal Disease
Frequent urinary tract infections
Hematuria (blood in urine)
Kidney stones
Other kidney condition

□

□

ISA
15B
15C
15D
15E
15F
15G
151
16
16A
16B
16C
16D
16E
17
17A
17B
18

Anemia
Cancer (describe type below)
Leukemia
Lymphoma - Hodgkins
Lymphoma - non Hodgkins
Platelet disorder
Hemochromatosis
Other Hematologic/Oncologic
Genitourinary - male

Prostate disease
Sexually transmitted disease
Testicular abnormality
Other genitourinary condition
HIV
Divin!!

Are you a diver for the USAP?
Have you had the bends? (describe)

Any other medical condition NOT
listed above

□

□

For all "yes" answers provide details to include line number, age of onset, frequency of event, date of last episode, current medications,
other therapies and current status of the condition.

I certify that the information contained herein is complete and accurate to the best of my knowledge. I will inform the contractor's
medical staff ofALL medical/health changes, including medications that occur after submitting this form. I understand thatfailure to
provide any or all of the requested information may result in a denial of my application for assignment to the Arctic Regions. I also
understand that willfully providingfalse statements to a Federal agency or its representatives is a criminal offense.

Print Name

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Signature

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Date

Page 24 of 33

PARTICIPANT NAME

ARCTIC

DOB:

Age:

Gender:

If LabCorp is unable to find the Account # to bill to, have them search the Phone # or Fax #. This will bring up
our Account and allow them to bill the labs to us.
Dear Lab Collection (LabCorp or Physician)
This person is being considered for participation in the National Science Foundation's Arctic program.
Collect specimens for the indicated laboratory analyses: All results need to be translated to English.

Participant: Do not eat or drink for 8 hours before labs.
Required Arctic Panel
✔ Complete Blood Count with Differential (LabCorpTest
#005009)
✔ Blood Chemistries (LabCorp Test #322758) (Sodium,
Potassium, Chloride, Glucose, Creatinine, GFR/BUN,
Calcium)
✔ Hepatic Panel (LabCorp Test #322755) (Alkaline

phosphatase, Total Bilirubin, AST (SGOT) , ALT (SGPT))
✔ Lipid Panel (LabCorp Test #303756) (Cholesterol, HDL,
LDL, Triglycerides)
✔ Hepatitis B Total Core Antibody (Anti-HBc) (LabCorp
Test #006718)

Additional Labs
HgAlc (LabCorpTest#001453) (Diabetes, or if glucose
100 or greater)
HIV (LabCorpTest#083935) (Required if you elected
YES for volunteering for the walking blood bank
(United States Arctic Program Deployment Consent/
Authorization Documents -pg. 32)
TSH (LabCorpTest#004259) (History of
hyper/hypothyroidism)

✔ Hepatitis C Antibody (Anti-HCV) (LabCorp Test

#144050)

✔ RPR (Syphilis) (LabCorp Test #006072)

✔ Blood Type (ABO and Rh) (LabCorp Test #006049)
✔ Quantiferon TB (LabCorp Test #182879)
✔ MMR Titer (LabCorp Test #058495)

Additional Information:
NOTE: Lab results ordered under our LabCorp Account # will not automatically be sent to a participant's physician.
All participants are responsible for their results and following up/reporting results to their physician. In the event of any
abnormal results, it is the participant's responsibility to follow-up with their provider to evaluate these and receive
further management/care.
If our Medical Director’s NPI # or account # was used to collect the lab work (CU) will be able to access these
results directly from LabCorp. You can get a copy of your labs at http://patient.labcorp.com Please allow a few
days to get your lab into their system. Once you have signed up it may take a few hours before you see your
results.
If any other lab or Physician’s office collects the lab work, even if they use Lab Corp, CU Polar Medicine will
not receive the results! You must submit these results with your PQ packet. FAX: 303-724-5649
NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 25 of 33

ARCTIC

Dear Doctor:

PARTICIPANT NAME

DOB:

Age:

Gender:

This person is being considered for participation in the National Science Foundation's Arctic Program. Arctic
medical facilities have limited diagnostic and therapeutic capabilities. In the event of a severe injury or medical
emergency, transportation to a modem hospital or clinic may take several days or longer. Environmental
conditions in the Arctic Regions may be harsh. Temperatures range from 100 degrees above to 65 degrees
below zero Fahrenheit. Physiologic altitude varies from 0 to over 10,000 feet above mean sea level. Participants
may live in close quarters for extended periods of time in constant daylight or darkness. Your clinical
assessment will be used to determine the person's physical qualification for deployment to the Arctic Regions.
Conduct the indicated tests and provide the results to the Participant in English.
Required Vaccinations:
✔

✔
✔
✔

TDap (Pertussis): Participants should receive a tdap if you have not had one in the last 10 years.
Seasonal Influenza: Yearly (exception for Arctic participants deploying in late spring/summer)
Measles (if not immune)
COVID-19 (CDC up-to-date recommendations) - Must complete CDC up-to-date recommendations for
vaccination at least 14 days prior to deployment.

Testing:
✔ Medical History Forms (pages 20-24) (Signed, dated)
✔ Arctic Physical Examination (pages 27-28)
EKG - 12 lead with tracing or rhythm strip (all new participants; then, age 40-49 every 5 yrs; then, age 50+
annually)
Exercise Stress Test with MD Interpretation (Summer Participant: required only if FHR score greater than 20%)
(Bruce Protocol - must complete 9 minutes, stage 3, 85% max heart rate)
Pulmonary Function Test, Pre/Post Bronchodilator (history of asthma, emphysema, or COPD OR occupational
PFT (spirometry for work))
Guaiac Stool Test (Age 50+)
Mammogram (females) (radiology) (Age 40+, every 2 years)
Chest X-Ray (Per TB protocol for positive PPD/ Quantiferon; or symptomatic pulmonary disease) (Submit report
only, not actual films).
Low-dose CT of the chest (Age 55-80 AND at least 30 pack-yr history AND current smoker or quit less than 15
years ago)

All participants are responsible for their results and following up/reporting results to their
physician. In the event of any abnormal results, it is the participant's responsibility to follow-up with
their provider to evaluate these and receive further management/care.
Prescription medications (type and quantity) are limited at all Arctic medical facilities. Participants are required to bring
a sufficient supply of medications for the duration of their deployment or make the necessary arrangements for
shipment of medication in accordance with provided guidelines found within the Arctic Physical Qualification
Important Information attachment.
NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 26 of 33

PARTICIPANT NAME

ARCTIC

ARCTIC PHYSICAL EXAMINATION

MUST BE COMPLETED BY M.D., D.O., P.A., OR N.P.
Name:

Date of Birth:

Blood Type:

New Government regulations require that you be informed of the following:
“The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from
requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this
law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical
information.
‘Genetic information’ as defined by GINA, includes an individual's family medical history, the results of an individual's or family
member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic
information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family
member receiving assistive reproductive services.”
Therefore, you should not forward any information related to the patient’s family’s medical history and only submit answers to those
questions regarding this patient’s personal/individual history.
VISION

VITAL SIGNS

Height:

Without Correction

Weight:

DIST
BP:

/

BMI:

With Correction
DIST
IST

NEAR

Pulse:

R

R

Framingham
Risk Score:

L

L

Finding
inding

Normal

Abnormal

Finding

NEAR

Normal

Abnormal

General appearance

Inguinal, include hernia

Head and neck

Genitalia male/female (Not Deferrable)

Eyes

Rectal male/female (Not Deferrable)

Ears

Spine

Nose

Upper extremities

Mouth

Lower extremities

Thyroid

Skin (include body)

Lymph nodes

Vascular

Chest and lungs

Neurologic

Breasts male/female (Not Deferrable)

Emotional Status

Heart

Pelvic exam (female, Not Deferrable)

Abdomen

Prostate exam (male age 40 & over)

Guaiac Test (annually, age 50 and over):

Influenza Vaccination (annually; must be for the flu season
that corresponds to deployment):

Result

Date

(Mandatory for deployment)
Date
TDap Vaccination (every 10 years):
Must include lot number, expiration date, manufacturer,
date of injection. Please attach CDC compliant proof of
vaccination.

NSF Form 1700 (rev October 2017)
OMB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Date
Page 27 of 33

ARCTIC PHYSICAL EXAM/NATION FORM

ARCTIC

PARTICIPANT NAME

Examiner - Comment on all abnormal findings

Examiner - Comment on overall fitness and health conditions that might interfere with the Participant's ability to participate in a

remote arctic deployment.

D
D
D

Overall fitness of the participant is good.
Participant is able to participate and complete duties in a remote arctic environment.
Participant will require further evaluation prior to clearance. (Comment or Recommendation)

Examiner's Name (printed with credentials)
This exam is void without credentials.

Signature

Date

Examiner Street Address:�-----------------------------------City: ___________________ State: _____ Zip Code: _____________
Office Phone: ________________ Office Fax:____________________
Return the completed examination form and results of the requested tests to the Participant.
NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 28 of 33

ARCTIC

PARTICIPANT NAME

Dear Dentist:
This person is being considered for participation in the National Science Foundation's Arctic program. The
Arctic Regions are isolated and lack dental facilities. Participants must be free of dental disease. There must
be no caries, active periodontal disease, potential endodontic disease, prosthetic deficiencies, potentially
symptomatic wisdom teeth, or any uncompleted treatment. All dental work must be completed and
documented.

Following the dental exam, the candidate should provide documentation of:
I. DENTAL EXAM

Chart all existing restorations, missing teeth, and endodontically treated teeth only on the Dental
Examination Form. The treating dentist must sign the Dental Examination Form and document all
completed work.

II. TIDRD MOLARS

Treatment mnst he completed three weeks prior to deployment in order for the dental condition to stabilize
before deployment. Third molars must be extracted only if they are symptomatic.w:.any of the following
are present:
1. Periodontal probe can contact the crown of an unerupted third molar
2. Bleeding or poor hygiene is evident in the third molar area
3. Pseudo pockets, bony pockets are present
4. Soft tissue extends onto the occlusal surface of the third molar

III. RADIOGRAPHS

Digital radiographs can be e-mailed in high-resolution JPEG format (preferred) or printed and sent in high
resolution on glossy photographic paper. Original mounted radiographs can be included with the Dental
Exam Form. Copies or poor quality radiographs will not be accepted. Radiographs become a part ofthe
participant's USAP record and WILL NOT BE RETURNED. You may wish to use a double film pack to
retain original radiographs for yourself. Necessary radiographs include:

IV. ORTHODONTICS

1.

Set of four ORIGINAL bitewing x-rays mounted- showing crestal bone and all posterior teeth
and contacts clearly. These films must be taken within 12 months of PQ packet submission and
must accompany the completed examination form.

2.
3.

Panoramic and/or mounted full mouth survey - a one time requirement.
A periapical (PA) film of all endodontic work, crowns, and extensive restorations

Orthodontic care is not available in the Arctic Regions; so, Participants with fixed orthodontic appliances
or undergoing any active treatment may be considered for short deployments, but only with written
approval from the attending provider and approval from the ASC Dental Reviewer.
1. Unrestricted Clearance - Fixed or removable orthodontic retainer only, with no active appliance.
2. Restricted Clearance for deployments up to six months - Candidates undergoing orthodontic
treatment who do not require treatment for the period of deployment and who have not had active
treatment for two months prior to deployment.

After completion, please return a copy of results to the participant. Copies of the dental exam form can be
faxed to 303-724-5649.
E-mail x-ray JPEG's to: [email protected]. Dental X-ray JPEGs CANNOT be faxed.
Mailing Address:
If shipping by USPS (preferred mailing service):
CU Polar Medicine
Attn: Kellie Schiller, Elaine Reno
Mail Stop C328
12631 E 17th Ave, Room 2509, Aurora, CO 80045
NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

If shipping by FedEx, UPS, DHL or any other mailing service:
CU Polar Medicine/Kellie Schiller
Dept. of Emergency Medicine
12631 E 17th Ave, Aurora CO 80045
Academic Office One, Room 2509
802-275-6367

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 29 of 33

ARCTIC DENTAL EXAM FORM

ARCTIC

PARTICIPANT NAME

ARCTIC DENTAL EXAMINATION
Name:

Date of Birth:

Email Address:

Day Telephone#:
Last Deployment Dates:

From:

Estimated Deployment Dates:

From:

To:

Chart existing restorations, missing, and endodontically treated teeth only:

-

UPPER
PALATAL

I

--�

V

(I

�

I

'"::-<,.

'I

.�

,,.. "·

I l'I I
,'\._J

J',......,

-.,y

�

I) (Il

2
31

3
30

4
29

5
28

6
27

7
26

8
25

9
24

10
23

11
22

12
21

13
20

14
19

-✓

(I

-"LOWER
FACIAL

��
I

' ' ��
I I1 I

- r,,
I
l

'----7'1-:

/'-.:__,/

□

-

15
18

16
17

�

L

�

I

D NO

□ NO

THIRD MOLAR EVALUATION

□ YES □ NO

3rd Molars Present

I I I I I I I I I I I I I I I I I I
LOWER
LINGUAL

Probings 5 mm or greater D YES
Active Disease Noted
YES

_,,"

I I I I I I I I I I I I I I I I I I
1
32

To:

PERIODONTAL EVALUATION

I I I I I I I I I I I I I I I I I I

UPPER
FACIAL

I Age:

List partially erupted

List impacted that can be probed
List fully impacted

List potentially symptomatic

IJ
J

I I I I I I I I I I I I I I I I I I

List implants

List retained 1 ° teeth

Documentation of all treatment identified and rendered and ori11inal radio11ranhs must accomnanv this form.
DATES
DATES
Dia1mosis and tr<>.. tment ne<>ded
List all treatment comnlet<>d

□

� BITEWING X-RAYS, SET OF FOUR MOUNTED
SHOWING ALL POSTERIOR TEETH
X-Ray cannot be older than 12 months
Date taken:

Attach the following ORIGINALS to this exam:
PANO OR FULL MOUTH SERIES
Required first deployment only.

at the time of dental review by CU
Polar Medicine.

Date of last Pano or Full Mouth Series:

I have thoroughly examined this candidate for travel to the Arctic Regions. All necessary treatment has been performed; all evaluations
completed; and the appropriate diagnostic radiographs will accompany this completed form as requested by the "Dear Dentist" letter.

TELEPHONE NUMBER (include area code):

DENTIST'S NAME (PLEASE PRINT)

STREET ADDRESS
DENTIST'S SIGNATURE

DATE

Date of Dental Exam: ______________________________
ATTENTION EXAMINING DENTIST:

Return this completed form, all documentation of treatment and
all ORIGINAL X-rays (digital preferred) to the Participant.

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

CITY

STATE

ZIP

ARCTIC MEDICAL STAFF USE ONLY

□ PQ

□ WINTER REVIEW

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

□ NPQ

Page 30 of 33

ARCTIC

PARTICIPANT NAME

UNITED STATES ARCTIC PROGRAM
DEPLOYMENT CONSENT/AUTHORIZATION DOCUMENTS
IMPORTANT NOTICE FOR PARTICIPANTS IN THE UNITED STATES ARCTIC PROGRAM
Participants in the United States Arctic Program (USAP) are expected to comport themselves in such a manner that their
activities and demeanor reflect credit on themselves and their sponsoring organizations. The special circumstances and
conditions prevailing in the Arctic require high standards ofconduct.
The potential for mishap in the Arctic Regions is a constant threat. Your ability to deal effectively with a mishap is reduced
if you are under the influence ofalcohol or other drugs. The National Science Foundation (NSF) will not condone abuse of
alcohol or controlled substances at its facilities. Unauthorized or excessive use ofsuch substances will not be tolerated.
The laws ofthe United States prohibit the possession, shipping, or mailing ofillegal drugs. In addition, governments in Arctic
countries have strict laws forbidding the possession or transportation through their countries offirearms, knives,
pornographic materials, marijuana or non-prescription drugs. These laws are strictly enforced and penalties for violation are
severe. Like any traveler, you must abide by applicable foreign law. Ifyou are found in violation thereof, you are subject to
prosecution in the courts ofthat country. Association with the Arctic programs affords neither preferential treatment nor
immunity from prosecution.
Conviction for any criminal action under the laws ofthe United States or foreign countries may result in your removal from
participation in the Arctic programs.
I have read and understand this Important Notice for Participants in the United States Arctic Program.
Initials
MEDICAL RISKS FOR NSF-SPONSORED PERSONNEL TRAVELING TO THE ARCTIC
Travel to the Arctic imparts certain risks to the traveler. You may experience extremely cold (subzero) temperatures, high
altitude and other environmental conditions that put you at risk for cold-related injuries. The limitations in the medical care
available and difficulties, in emergencies, ofproviding timely evacuation to tertiary medical care facilities in the U.S. or other
countries increase your risk ofserious complications from exposure or lack ofimmediate medical care. Extremes ofdaylight
and darkness can impact sleep or other behaviors. Living in close quarters increases the likelihood of exposure to
communicable diseases. Participants should consider these risks before deciding to deploy.
Arctic. A contracted paramedic is on staff at Summit Station on the Greenland Ice Cap. Facilities for emergency care are
available (although rarely used) at Kangerlussuaq (western) and Thule Air Base (northern) in Greenland. Virtual or other
emergency health care support may be made available for certain remote Arctic locations; e.g., medical kits and access to
medical advice via satellite telephone. Researchers and support personnel at other Arctic locations, such as Alaska, Canada,
Russia, etc., are typically able to avail themselves of locally available commercial care. Partly because ofthese limitations,
NSF requires medical and dental screening ofpersonnel prior to deployment. These medical screening examinations are
necessary to determine the presence ofmedical conditions that could threaten the health or safety ofthe individual while
deployed. They are also necessary to determine whether medical conditions exist that cannot be effectively managed while
the individual is deployed. Persons who fail to meet these medical/dental screening criteria will be notified of the specific
reason(s) for their disqualification.

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 31 of 33

UNITED STATES ARCTIC PROGRAM DEPLOYMENT CONSENT/AUTHORIZATION DOCUMENTS

ARCTIC

PARTICIPANT NAME

Participants should realize that serious accidents or injuries might challenge the medical care system. Therefore, individuals
should recognize the limitations in the medical care system before they engage in any risk-taking behaviors (whether
on-the-job or during recreational pursuits) that may result in accidents or injuries.
Data collected as a result ofthis medical screening requirement are maintained in accordance with the Privacy Act (5
U.S. Code 552a) and protected against unauthorized release, as described in the appended Privacy Notice found in the Arctic
Physical Qualification Important Information Packet. The collection ofthis information must display a currently valid 0MB
control number. You are not required to respond to the collection ofthis information unless it displays a currently valid 0MB
control number.
_________ I have read and understand the Medical Risks for NSF-Sponsored Personnel Traveling to the Arctic.
Initials
MEDICAL SCREENING FOR BLOOD-BORNE PATHOGENS
As described above, medical clinics at the NSF research stations in the Arctic do not have or maintain readily available
supplies offrozen blood. In the event ofthe need for a transfusion, other individuals at the research station with matching
blood types would be asked to donate fresh whole blood for the patient. In order to maintain a viable donor pool, NSF
requests that U.S. Arctic program participants during the respective austral summer seasons voluntarily submit to testing for
Human Immunodeficiency Virus (HIV) along with the required Hepatitis virus B and C as part oftheir medical screening
process. Please note that HIV testing is required for candidates intending to spend the winter in Antarctica or in the Arctic.
[Whether you are voluntarily consenting to this testing (summer only) or required to do so (winter deployment), you should
take this form with you to your laboratory appointment to ensure that the tests are performed.]
CONSENT FOR HIV ANTIBODY BLOOD TEST

I have been informed that my blood will be tested for Human Immunodeficiency Virus (HIV) antibodies, the causative agent
ofAcquired Immune Deficiency Syndrome (AIDS). I understand that the testing involves the withdrawal ofa small amount
ofmy blood by venipuncture and subsequent testing ofthat blood sample via ELISA (Enzyme-Linked Immuno-Sorbent
Assay) and Western Blot methods.
I understand that ifl have any questions regarding the testing procedure or interpretation ofresults, I should discuss them
with my health care provider. I understand that my examining physician will receive a copy ofthese test results and may be
required, under State law, to report positive test results to state health department authorities, and I consent to these
disclosures.
I understand that the results of this blood test will be incorporated into my USAP medical file. All information in that file is
maintained in accordance with the Privacy Act (5 USC 552a) and protected against unauthorized release, as described in the
appended Privacy Notice found in the Arctic Physical Qualification Important Information Packet.
I volunteer for the Walking Blood Bank, should a medical emergency develop while I am on station that requires a blood
donation to help save a human life. Yes

D

No

D

____ I have read and understand the above Medical Screening for Blood-Borne Pathogens information.
Initials

D

D

Having read and understood the above statements, I hereby
GIVE
DO NOT GIVE
____ my consent to the collection and testing ofmy blood to determine the presence ofHIV antibodies ifrequired.
Initials
I have read and understand the United States Arctic Program Deployment Consent/Authorization Documents.
______________________________________
Signature
Participant Note: The Walking Blood Bank is for USAP only. Response is used if PQ is transferred from CU Polar
Medicine to UTMB for Antarctica PQ.
NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Page 32 of 33

UNITED STATES ARCTIC PROGRAM DEPLOYMENT CONSENT/AUTHORIZATION DOCUMENTS

ARCTIC

PARTICIPANT NAME

AUTHORIZATION FOR TREATMENT OF FIELD-TEAM MEMBER/PARTICIPANT UNDER 18 YEARS OF AGE
I am the parent or legal guardian of
, who is an underage participant in the National Science
Foundation/Geosciences/Division of Arctic Programs. Should any medical/dental care be required during his or her
deployment to the Arctic, I hereby give my authorization and consent to the National Science Foundation's Division of
Arctic Programs' medical care provider(s) for any medical care, treatment or procedures that are deemed medically
necessary while my son or daughter is deployed to the Arctic.

Name of Parent or Legal Guardian

Street Address

City State

Zip Code

Telephone Numbers
Daytime: _________________

Print Name

NSF Form 1700 (rev October 2017)
0MB CONTROL NUMBER: 3145-0177
Expires: SEP 2020
(Previous versions are not authorized.)

Evening: _____________

Signature

Arctic Physical Qualification (PQ) Packet
Applicants: Please retain one copy for your records

Date

Page 33 of 33