MEDICAL EVALUATION CHECKLIST

Status: Original and derived artifacts are available for this document.

Download: pdf

OMB Control Number: 0648-0822
Expiration Date: 05/31/2027
NOAA Form 57-03-52
(01-25)
Page 1 of 6

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

REPORT OF EXAMINATION AND MEDICAL HISTORY - DIVER

INSTRUCTIONS: The NOAA Diving Physical report consists of three parts. Page one contains contact information, checklists of required medical
tests, attestation by the diver and approval by the NOAA DMO. Pages 2-3 are the diver's self-reported medical history. Examiner, please review
pages 1-3, summarize the diver's medical condition, and then fill out items 88 and 89, "Examiner Review". Pages 4-6 contain the results of the
medical exam and tests, as well as the signature of the medical professional conducting the exam. The Examiner must be either a Medical
Doctor (MD), Doctor of Osteopathy (DO), Nurse Practitioner (NP), or Physician’s Assistant (PA). Submission instructions are on the final page.
All tests must be completed within the last 12 months, unless otherwise indicated in the checklist below.
LAST NAME
FIRST NAME
MIDDLE NAME
DATE of BIRTH

WORK E-MAIL ADDRESS

BEST CONTACT PHONE NUMBER
UNIT DIVING SUPERVISOR'S NAME

DIVE UNIT
UNIT DIVING SUPERVISOR'S E-MAIL ADDRESS

DUTY STATION ADDRESS

REQUIRED FOR ALL EXAMINATIONS

MEDICAL EVALUATION PACKET CHECKLIST

NOAA Form 57-03-52 Report of Physical Examination and Medical History – Diver
Complete Blood Count (CBC)
Complete urinalysis
Near and distant vision tests – results
DEPENDING ON YOUR AGE, HABITS, OR WHETHER THIS IS AN INITIAL OR PERIODIC EXAM, THE FOLLOWING TESTS MAY ALSO BE REQUIRED:
All INITIAL EXAMINATIONS must include these additional test results

Spirometry test – results and interpretation
Audiogram – results and interpretation
Chest X-ray interpretation within the past 24 months (no films)
All 40 and OLDER EXAMINATIONS must include these additional test results

12-Lead resting EKG – results and interpretation
Lipid screening – total cholesterol, HDL, LDL, and triglycerides
Hemoglobin (HgA1c) or fasting glucose screening
All PERIODIC EXAMINATIONS must include this additional test (SMOKERS ONLY)

Spirometry test – results and interpretation
APPLICANT CERTIFICATION

(initial each item and sign below):

______ I have reviewed the attached medical information and consider the application package to be complete and accurate.
______ I acknowledge that it is my responsibility to notify the NOAA Diving Medical Officer of any medical condition, illness,
injury, medical treatments, and/or surgeries, or any changes to the above, as they occur.
______ I acknowledge it is my responsibility to also notify my UDS and the DM/LD of any conditions or restrictions that will
affect my diving on any given day. Failure to do so could compromise the mission and endanger myself or my fellow divers.
I certify that the attached medical information in the package is complete and true to the best of my knowledge:
APPLICANT NAME
APPLICANT SIGNATURE

DATE

NOAA DIVING OFFICER APPROVAL
Final determination of the diver's medical suitability for NOAA diving will be made by the NOAA Diving Medical Officer.
I have reviewed the attached medical information and have found the applicant named above to be:

Medically cleared for NOAA diving duty
DIVING MEDICAL OFFICER NAME

Not medically cleared for NOAA diving duty
DIVING MEDICAL OFFICER SIGNATURE

DATE

NOAA Form 57-03-52
(01-25)
Page 2 of 6

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

REPORT OF MEDICAL HISTORY - DIVER

The diver should fill out this page and give the completed page to the Examiner for review.
1a. LAST NAME
1b. FIRST NAME
1c. MIDDLE NAME

3. AGE

4. SEX

5. HEIGHT
(inches)

8. STATEMENT OF PRESENT HEALTH

6. WEIGHT
(pounds)
9. ALLERGIES

2. DATE of BIRTH
7. DATE

List all allergies: insect bites, stings, foods, and medicines
11. CURRENT PRESCRIPTION and NON-PRESCRIPTION MEDICATIONS
Indicate dosage, frequency, and condition being treated

10. Do you carry an Epi-Pen?
PAST MEDICAL HISTORY: Have you ever had the following? Check each item.
YES NO
12. Adverse reaction to medication
24. Pain or pressure in the chest
13. Tuberculosis or positive TB test
25. Palpitation, pounding heart, or abnormal heartbeat
14. Exposed to someone who had tuberculosis
26. Heart murmur or other disorder
15. Asthma or any breathing difficulty
27. Heart or blood vessel surgery
16. Used or have been prescribed an inhaler
28. Abnormal heart anatomy or patent foramen ovale
17. Plates, screws, rods, or pins in any bone
29. Diabetes
18. High or low blood sugar
30. High cholesterol
19. Sugar, albumin, or blood in the urine
31. Stroke
20. Tumor, growth, cyst, or cancer
32. Heart disease
21. Aneurysm, frequent or severe headaches
33. Parent or sibling with condition indicated in 29-32
22. Seizures, convulsions, epilepsy, or fits
34. Treated in a decompression chamber
23. Other neurological disorder or injury
35. Medical disqualification for diving duty
PAST MEDICAL HISTORY: Have you had the following in the last ten years? Check each item.
YES NO
36. Thyroid trouble or goiter
51. Rectal disease, hemorrhoids, bleeding from rectum
37. Eye disorder or trouble
52. Shortness of breath or wheezing
38. Surgery to correct vision (i.e. RK, PRK, LASIK )
53. Sinusitis, bronchitis, or frequent colds
39. Recurrent back pain or any back problem
54. Kidney, bladder, or urination problems
40. Nerve injury, numbness, tingling, or sensitive areas
55. Head injury, memory loss, or amnesia
41. Loss of finger or toe
56. Concussion or period of unconsciousness
42. Knee trouble (locking, giving out, pain, injury)
57. Dizziness or fainting spells
43. Leg cramps
58. Prolonged bleeding, blood clot, or embolism
44. Painfull or swollen joints
59. High or low blood pressure
45. Arthritis, rheumatism, tendinitis, or bursitis
60. Depression, anxiety, or claustrophobia
46. Artificial joint or other deformity
61. Received counseling of any type
47. Bone fracture or deformity
62. Been evaluated or treated for a mental condition
48. Stomach or intestinal trouble
63. Attempted or planned suicide
49. Jaundice, hepatitis, or liver disease
64. Inability to focus or pay attention
50. Hernia or rupture
65. Ear infection
CURRENT MEDICAL HISTORY: Do you currently have any of the following? Check each item.
YES NO
66. Severe tooth or gum trouble
74. Use of prosthetic / corrective devices or braces
67. Wear glasses or contact lenses
75. Frequent indigestion or heartburn
68. Lack of vision in either eye
76. Skin disease (i.e. acne, eczema, psoriasis)
69. Hay fever or allergic rhinitis
77. Recent unexplained weight loss or gain
70. Ear, nose or throat trouble
78. Motion sickness (kinetosis)
71. Hearing loss or wear a hearing aid
79. Difficulty distinguishing colors or seeing at night
72. Impaired use of arms, hand, legs or feet
80. Difficulty performing moderate to heavy exercise
73. Foot problems
81. Currently pregnant/may be pregnant (women only)

YES

NO

YES

NO

YES

NO

YES

NO

NOAA Form 57-03-52
(01-25)
Page 3 of 6

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

REPORT OF MEDICAL HISTORY - DIVER

The diver should fill out this page and give to the Examiner. Examiner, please review pages 2-3 and then fill out items 88 and 89 below.
LAST NAME
FIRST NAME
MIDDLE NAME
DATE

82. Indicate the type and frequency of use for the following:
a. Alcohol
b. Tobacco

c. Recreational drugs

PAST DIVE MEDICAL HISTORY: Have you ever had the following as a result of diving? Check each item.
YES NO
83a. Ear or sinus squeeze
g. Near drowning
b. Inability to equalize middle ear pressure
h. Arterial gas embolism (AGE)
c. Ruptured ear drum
i. Oxygen (O2) toxicity
d. Vertigo (dizziness)
j. Carbon dioxide (CO2) toxicity
e. Loss of consciousness or asphyxia
k. Type I DCS (pain only, itching, rash, swelling)
f. Lung squeeze or collapsed lung (pneumothorax)
l. Type II DCS
84. Indicate any other medical conditions not listed above.

YES

NO

85. Indicate date, location, and reason for each hospitalization and surgery had or advised to have within the last ten years. Indicate reasons for
any declined surgery.

86. Provide a detailed explanation for each item checked “YES” in either Medical History section. Add additional pages if necessary.

APPLICANT CERTIFICATION
87. I certify that I have reviewed the medical information provided by me. It is true and complete to the best of my knowledge. I understand
that falsification of information on a Government form is punishable by fine and/or imprisonment and that incomplete information may delay or
prevent my qualification for dive duty.
a. APPLICANT NAME

b. APPLICANT SIGNATURE

c. DATE

b. EXAMINER SIGNATURE

c. DATE

EXAMINER REVIEW
88. EXAMINER SUMMARY of DEFECTS

89a. EXAMINER NAME and TITLE

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

NOAA Form 57-03-52
(01-25)
Page 4 of 6

REPORT OF PHYSICAL EXAMINATION - DIVER

1a. APPLICANT LAST NAME 1b. FIRST NAME

1c. MIDDLE NAME

2. DATE of BIRTH

3. DATE of EXAM

Instructions to the Examiner:
The person requesting this physical examination is an applicant for training or currently participates in diving activities with self-contained
underwater breathing apparatus (SCUBA) or other similar equipment. Your opinion of the applicant’s medical fitness for diving is requested. The
Medical History and Physical Examination forms focus on conditions that may put a diver at increased risk for injuries or other conditions that
could lead to decompression sickness (DCS) or drowning. The diver must be able to withstand some degree of cold stress, high pressures of up to
six
(6) atmospheres,
the physiologic
effects
immersion,
the optical
effects
of water,
and provided
have sufficient
physical and
mental reserves to deal
PHYSICAL
EXAMINATION:
This section
mustofbe
fully completed
by the
examining
medical
(MD/DO/NP/PA
only).
with underwater emergencies. Final determination for fitness for diving will be made by the NOAA Diving Program.
The Examiner should review pages 2-3, complete fields 88 and 89 on page 3, complete a comprehensive physical examination of the diver, and
complete this page and all following pages. All tests and examinations must be completed in the last 12 months (except for the chest X-ray, which
should be completed within the last 24 months). The additional tests that must be completed are on page 1 of this form. If you conduct other
laboratory tests or diagnostic studies as part of this physical examination, include copies of these results with the submission of the other
required documentation. Submission instructions for this form and all test results are on the last page of this form.
For questions, please contact the NOAA Diving Medical Officer at (206) 526-6474.

5. EXAM TYPE
Initial
10. TEMP.
(°F)

6. AGE

7. SEX

11. PULSE

12. BLOOD
PRESSURE

8. HEIGHT
(inches)

Periodic

13. VISION CORRECTABLE TO 20/20?
Right eye Distant _____(Y/N)

Near _____(Y/N)

Left eye

Near _____(Y/N)

Distant _____(Y/N)

GENERAL CLINICAL EVALUATION: Check each item.
16. Head, face and scalp
17. Neck
18. Eyes
19. Fundus
20. Ears (external / external canals)
21. Eustachian tube function, can perform Val Salva
22. Tympanic membranes
23. Nose (septal alignment)
24. Sinuses
25. Mouth and throat
26. Dental (loose or decayed teeth)
27. Lungs and chest (including breasts)
28. Heart (thrust, size, rhythm, sounds)
29. Pulses (equality, etc.)
30. Vascular system (varicosities, etc.)
31. Abdomen and viscera
32. Hernia (all types)
33. Feet (arch, pes cavus / planus)
34. Spine
35. Skin, lymphatics

9. WEIGHT
(pounds)

2nd BP
(if needed)

/

14. NEED CONTACT LENS
USE WHILE DIVING OR
PRESCRIPTION DIVING
MASK?
YES

NO

Normal

Abnormal

/

3rd BP
(if needed)

/

15. NEAR VISION
Right eye 20 / _____

Corrected to 20 / _____

Left eye

Corrected to 20 / _____

20 / _____

Description of abnormality

NOAA Form 57-03-52
(01-25)
Page 5 of 6

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

REPORT OF PHYSICAL EXAMINATION - DIVER

1a. LAST NAME

1b. FIRST NAME

1c. MIDDLE NAME

3. DATE of EXAM

NEUROLOGIC EXAMINATION: Check each item
36. Sensorium (Consciousness, intellectual, cognitive function) Normal ______ Abnormal ______
37. Cranial Nerves: (normal/abnormal)
I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear

V. Trigeminal
VI. Abducent
VII. Facial
VIII. Auditory

38. Reflexes:

Deep Tendon (grade 0 – 3+, 2+ = normal)
Left

Brachioradialis
Biceps
39. Cerebellar Function
Gait
Tremor (intention)
Finger to nose
Heel to shin slide
Romberg sign

Normal

Right

Abnormal

Patella
Achilles

Left

Right

Left

Right

Right

Hoffman
Ankle clonus

Left

Right

-

-

41. Nystagmus (+/- = presence/absence)

Joint position sense
Vibratory sensations
Stereognosis
(ability to recognize
objects by touch)

End point (physiologic)

-

Pathological

-

Left

Hips: Flexion
Extension
Abduction
Adduction

43. Range of Motion (+/- = normal/abnormal)
Shoulders
Elbows

Pathological (+/- = presence/absence)
Left

40. Proprioception (+/- = presence/absence)

42. Muscle Strength (grade 0 – 5, 5 = normal)
Deltoids
Latissimus
Triceps
Biceps
Forearms
Hands
Fingers

IX. Glossopharyngeal
X. Vagus
XI. Spinal Accessory
XII. Hypoglossal

Hips
Wrist

Left

Right

Right

Knees: Flexion
Extension

Left

Right

Left

Right

Ankles: Dorsiflexion
Plantarflexion
Inversion
Eversion

Left

Right

Knees
Ankles

44. Sensation (sharp dull, two-point discrimination) Diagram and label areas of altered sensations, and surgical and traumatic scars.

NOAA Form 57-03-52
(01-25)
Page 6 of 6
1a. LAST NAME

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

REPORT OF PHYSICAL EXAMINATION - DIVER
1b. FIRST NAME

1c. MIDDLE NAME

3. DATE of EXAM

45. Summary of Laboratory/ancillary data. Transcribe results below or attach official laboratory report. Tests below are representative of
standard analyses, yours may not list every test. Submit all test results provided.
COMPLETE URINALYSIS
Spec. Gravity
Ph
Color
Clarity
Leuk Esterase
Protein
Glucose
Ketones
Occult Blood
Bilirubin
Urobilirubin
Nitrite

METABOLIC DATA
Glucose
BUN
Creantine
eGFR
BUN/Cr
Sodium
Potassium
Chloride
CO2
Calcium
HgA1C

AUDIOMETRY (Only for initial physical)
HZ
500
1000
2000
Left
Right
CBC DATA
WBC
RBC
Hg
Hct
MCV
MCH
MCHC
RDW
Platelets

3000

4000

6000

LIPID PROFILE
Total
Triglycerides
HDL
LDL
VLDL
LDL/HDL Ratio

46. All abnormal physical findings must be described in detail here by number. Add additional pages if necessary.

47. Although the NOAA Diving Medical Officer will make the final determination regarding fitness for duty as a diver, are there any further
concerns to this applicant’s fitness for diving?

48. EXAMINATION LOCATION NAME and ADDRESS

49a. EXAMINER NAME

49b. PHONE NUMBER

49c. EXAMINER TITLE
49d. EXAMINER SIGNATURE

49e. DATE

SUBMISSION INSTRUCTIONS
This form must be sent via a secured file transfer method such as a password-protected PDF, or Accellion (Kiteworks) File Transfer. Files sent
from a NOAA.GOV email address to the [email protected] email address are secure and do not need to be encrypted further.
Email is the preferred submission method.
Or, mail to:
NOAA Diving Medical Officer (DMO)
Email to: [email protected]
NOAA Diving Program
Subject: "Report of Physical Exam - Diver (last name)"
7600 Sand Point Way NE
Seattle, WA 98115

PRA Public Burden Statement
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 0648-XXXX. Without this approval, we could not conduct this information collection. Public reporting for this information collection
is estimated to be approximately 2 hours 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 required to obtain benefits. Send comments regarding this burden estimate or any other aspect of this information
collection, including suggestions for reducing this burden to the NOAA Diving Center Executive Officer, NOAA Diving Program, 7600
Sand Point Way NE, Building 8, Seattle, WA 98115, 206-526-6460.
Privacy Act Statement
Authority: The collection of this information is authorized under 29 CFR 1910, Subpart T, Commercial Diving Operations. Additional
authorities include 29 U.S.C. 653, 655, 657; 40 U.S.C. 333; 33 U.S.C. 941; Secretary of Labor's Order No. 8-76 (41 FR 25059), 9-83 (48 FR
35736), 1-90 (55 FR 9033), 6-96 (62 FR 111), 3-2000 (65 FR 50017), 5-2002 (67 FR 65008), 5-2007 (72 FR 31160), or 4-2010 (75 FR 55355)
as applicable, and 29 CFR 1911.
Purpose: NOAA is collecting this information to assess an individual’s medical fitness to dive, proficiency, and further training.
Information will also be used to ensure diving equipment is safe and well maintained and that all policies are being adhered to for safety
reasons. Aggregate data is used for annual reports and other leadership documents.
Routine Uses: NOAA will use this information in the determination of an individual’s medical fitness to dive. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related
purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of
Records Notice NOAA-10, NOAA Diving Program.
Disclosure: Furnishing this information is voluntary. However, the failure to provide complete and accurate information will exclude the
individual from NOAA’s Diving Program.