Form NIST-986 Health Record

OMB Control Number: 0693-0080 Expiration Date: 08/31/2024
NIST-986
(REV. 4-2021)
NIST P 7100.00

U.S. DEPARTMENT OF COMMERCE
NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY
Date:

HEALTH RECORD

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with information solicited. All information listed
below is given voluntarily and is confidential. It will be used only by the Health Unit in a medical emergency.
Name (Last, first, middle initial)
Date of Birth

Male

Work Telephone Number

Email Address

Job Title

Division

Female
Mail Stop
Building

Room

Supervisor/Sponsor

Supervisor/Sponsor Telephone Number

Home Address

Personal Telephone Number

Private Physician (Name, address, telephone number)

Emergency Contact(s)
Relationship: _______________________

1. Name:
Phone #:
2. Name:

Relationship: __________________________

Phone #:
I give consent to the above named person(s) to access any and all medical information related to me.
I am the only person authorized to access any and all medical information related to me. (In the case of incapacitation, state/federal laws would
take effect.)
Significant Medical Problems
Allergies - non-medication
Details
Arthritis/Chronic Pain
Asthma/COPD/Emphysema Other Lung Disorders
Cancer
Diabetes
High Blood Pressure

Allergies - medications

Kidney Disorders
Mental Illness/Anxiety/Depression
Seizures/Neurological Disorders
Stroke/Heart/Cardiovascular Diseases
Other:
Current Medications (and date started)

Chaperone Requested:

Yes

No

Preferred Pharmacy:
Pharmacy Address:

Phone #:

By signing below, I agree to the following: The above information is correct and true to the best of my knowledge. I have received and understand
the Notice of Privacy Practices, Health Unit Rights and Responsibilities, and Chaperone Policy. I have received and understand the Consent for
Care and fully consent to treatment.
Signature:

Date:

OMB Control Number:0693-0080 Expiration Date: 08/31/2024

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 0693-0080. Without this approval, we could not conduct this
information collection. Public reporting for this information collection is estimated to be approximately 10 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
voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including
suggestions for reducing this burden to the National Institute of Standards and Technology, Attn: Stephen Banovic,
[email protected].

PRIVACY ACT STATEMENT
Pursuant to 5 U.S.C. § 552a(e)(3), this Privacy Act Statement serves to inform you of why the U.S. Department of
Commerce (the Department), National Institute of Standards and Technology (NIST) is requesting the information on
this form.
AUTHORITY:
The collection of this information is authorized under The National Institute of Standards and Technology Act, as
amended, 15 U.S.C. 271 et seq. (which includes Title 15 U.S.C. 272) and section 12 of the Stevenson-Wydler
Technology Innovation Act of 1980, as amended, 15 U.S.C. 3710a. Includes the following, with all revisions and
amendments: 5 U.S.C. 301; 44 U.S.C. 3101; E.O. 12107, E.O. 13164, 41 U.S.C. 433(d); 5 U.S.C. 5379; 5 CFR Part
537; DAO 202-957; E.O. 12656; Federal Preparedness Circular (FPC) 65, July 26, 1999; DAO 210-110; Executive
Order 12564; Public Law 100-71, dated July 11, 1987. Executive Orders 12107, 12196, and 12564 and 5 U.S.C.
chapters 11, 33, and 63.
PURPOSE:
The Office of Safety, Health, and Environment (OSHE) supports the National Institute for Standards and Technology
in carrying out its mission safely and in maintaining safety as an integral core value and vital part of the NIST culture.
The NIST Health Unit will use this information to record medical or health information for individuals seeking medical
care on NIST campus; for recording of medical or safety equipment or incidents; to refer information required by
applicable law to be disclosed to a Federal, State, or local public health service agency, concerning individuals who
have contracted certain communicable diseases or conditions. Such information is used to prevent further outbreak of
the disease or condition; to disclose information to the appropriate Federal, State, or local agency responsible for
investigation of an accident, disease, medical condition, or injury as required by pertinent legal authority; to disclose
information, when an individual to whom a record pertains is mentally incompetent or under other legal disability, to
any person who is responsible for the care of the individual, to the extent necessary; to disclose to the Office of
Workers' Compensation Programs in connection with a claim for benefits filed. Disclosure of this information is also
subject to all the published routine uses as identified in the Privacy Act System of Records Notices:
Commerce/DEPT-18: Employees Personnel Files Not Covered by Notices of Other Agencies
OPM/GOVT-10: Employee Medical File System Records.
ROUTINE USES:
The information solicited on this form may be made available as a “routine use” pursuant to 5 U.S.C. § 552a(a)(7) and
(b)(3). The information may be made available to other federal agencies to assist the Department in connection with
NIST’s management of the purposes stated above; or for other authorized routine uses.
A complete list of the routine uses can be found in the system of records notice associated with this form,
“COMMERCE/DEPT-23: Information Collected Electronically in Connection with Department of Commerce
Activities, Events, and Programs; and COMMERCE/DEPT-13: Investigative and Security Records. These system of
records notices can be found on the Department's website at
https://www.osec.doc.gov/opog/privacyact/privacyact_sorns.html and OPM/GOVT-10: Employee Medical File
System Records at https://www.opm.gov/information-management/privacy-policy/sorn/opm-sorn-govt-10-employeemedical-file-systems-records.pdf

CONSEQUENCES OF FAILURE TO PROVIDE INFORMATION:
Providing this information is voluntary. However, failure to provide the requested information may result in an
inability for NIST to process, review, and/or act on such requests. In limited circumstances, NIST may authorize the
submission of the requested information via paper forms pursuant to the requirements in 15 CFR 748.1(d).

NIST-986 (REV. 4-2021)