Information Collection

Medical Clearance Process for Deployment to the Polar Regions

IC 211404 under ICR 202404-3145-001 · OMB 3145-0177.

Documents and Forms

Document Name Document Type
Form NSF-1700 Medical Clearance Process for Deployment to the Polar Regions Form and Instruction
NSF-1700 Medical History NSF 1700 APR24.docx Form and Instruction
NSF-1700 Medical History NSF 1700 APR24.docx Form and Instruction
NSF-1428-A Applicant Statement and Release of Liability 04 Applicant statement 1428.docx Form
NSF-1428-A Applicant Statement and Release of Liability 04 Applicant statement 1428.docx Form
NSF-1429-A Employer Endorsement and Release of Liability Employer Endorsement 1429.docx Form
NSF-1429-A Employer Endorsement and Release of Liability Employer Endorsement 1429.docx Form
Arctic PQ Information copy.pdf Physical Qualification Packet IC Document
Arctic PQ Information copy.pdf Physical Qualification Packet IC Document
Arctic PQ Packet 2024 copy.pdf Physical Qualification Packet Checklist and Packet Order IC Document
Arctic PQ Packet 2024 copy.pdf Physical Qualification Packet Checklist and Packet Order IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medical Clearance Process for Deployment to the Polar Regions	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	NSF-1700	Medical History	NSF 1700 APR24.docx	Yes	Yes	Fillable Fileable
Form	NSF-1428-A	Applicant Statement and Release of Liability	04 Applicant statement 1428.docx	Yes	No	Fillable Printable
Form	NSF-1429-A	Employer Endorsement and Release of Liability	Employer Endorsement 1429.docx	Yes	No	Fillable Printable

Line of Business: Education

Subfunction: Higher Education

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,700	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 90 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	3,700	50	3,650
Annual IC Time Burden (Hours)	37,000	500	36,500
Annual IC Cost Burden (Dollars)	1,184,000	16,000	1,168,000

Documents for IC

Title	Document	Date Uploaded
Physical Qualification Packet	Arctic PQ Information copy.pdf	04/12/2024
Physical Qualification Packet Checklist and Packet Order	Arctic PQ Packet 2024 copy.pdf	04/12/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.