Form NOAA Form 57-10-01 NOAA Form 57-10-01 NOAA Health Services Questionnaire with Tuberculosis Scr

NOAA Form 57-10-01
(3-14) Page 1 of 5

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

HEALTH SERVICES QUESTIONNAIRE
Application for Medical Qualification to Embark a NOAA Ship

INSTRUCTIONS FOR NOAA TEACHER AT SEA PARTICIPANTS
DUE - Thursday, March 21, 2019
1. Be sure to fill out all necessary fields and sign and date the form. A doctor’s signature is
required on the TB
(PPD) Screening Document, which must be submitted along with a copy of the test results. The form must be
legible and complete. nreadable or incomplete forms will be returned to the applicant.
2. Once you have completed the forms, please fax them to 301-263-7699 . DO NOT EMAIL DOCUMENT as it
contains private information that cannot be sent through email. Once we receive your form, we will send it to our
medical officer who will determine if you are fit for sea duty. You will only hear back from us about your form if
there is an issue. You will hear directly from the medical officer if they have a question.
Important Note: If you have any changes to your health (after you submit your medical form) or work
status, we ask that you contact us immediately, as these are important factors for participation in our program.

All positive responses in the General Screening and Cardiac Screening sections require a detailed
explanation in the space provided. The Continuation Page may be used if more space is needed. An indication of
hypertension requires the most recent blood pressure reading. An indication of diabetes requires the most recent
glycated hemoglobin (HbA1c) reading.
All persons embarked aboard a NOAA ship must have a test for tuberculosis (TB)
within the 12 months preceding the project end date. MOC Health Services accepts three tests
to detect exposure to the TB bacteria; the Purified Protein Derivative (PPD or TB skin test), the
QuantiFERON-TB test (QFT or TB blood test), and the T-spot blood test. PPD results must be
recorded in millimeters (mm) and not documented as positive or negative. QuantiFERON-TB
and the T-spot results must be indicated as negative, positive, or indeterminate. You must also
include a copy of the TB test from your doctor.
All persons embarked on a NOAA ship must be able to perform normal work functions
and minimal personal emergency response functions while the ship is underway. During an
abandon ship event, personnel may have to don a survival suit and/or descend a rope ladder to
a life raft or rescue craft. Personnel deploying in small boats for operations may have to
ascend and descend a rope ladder. A rope ladder (as pictured to the right) is a heavy duty
ladder with rigid rungs that hangs over the side of the ship used for underway embarkation and
disembarkation of personnel. A survival suit (as pictured to the right) is a full-body single-piece
coverall designed to provide thermal protection to personnel immersed in water. A person at
sea should be able to don a survival suit in one minute while fully clothed and without having
to remove shoes. All negative responses in the Functional Abilities Screening section require
additional explanation on the Continuation Page.
Do not write in the “MOC Health Services Use Only” section. Use the Continuation
Page to provide any additional information. Direct all questions regarding the information
required on this form to the MOC Health Services Medical Officer at MOC-Atlantic
(757) 441-6320.

NOAA Form 57-10-01 ( -1 )
Page 2 of 5
OMB Control Number 0648-0283
Expiration Date 9/30/2019

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

HEALTH SERVICES QUESTIONNAIRE
Application for Medical Qualification to Embark a NOAA Ship

Section I: Applicant Information
Applicant Name (Last, First Middle)

Year of Birth

Office, Laboratory or Institution Name

Work Phone

Work Address

Cell Phone

City

State

Zip Code

E-mail Address
Emergency Contact Name
Address
Project Dates

City

Today’s Date

Home Phone

Relationship

(Check one preferred contact
phone number above)
Cell Phone

State

Home Phone

Start

Zip Code
End

Project Ship(s)
Position

Scientist

✔ Teacher at Sea

Contractor
Volunteer

Other (specify below)
___________________________

Section II: Current Health Information – (provide additional information on page 4 if needed)
List all health problems / medical conditions which regularly require a physician’s attention.
1.
2.
None
3.
4.
List all medications (prescription and non-prescription) you currently take.
1.
5.
2.
6.
None
3.
7.
4.
8.
List all health problems / medical conditions which do not require a physician’s attention or medication.
1.
2.
None
3.
4.
List major surgeries, hospitalizations, and emergency room visits.
1.
2.
None
3.
4.
List all known allergies and subsequent reactions.
Allergy
Reaction
1.
1.
None
2.
2.
3.
3.

NOAA Form 57-10-01
( -1 ) Page 3 of 5

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

HEALTH SERVICES QUESTIONNAIRE
Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Section III: General Screening
Indicate any medical condition experienced during adulthood.
Yes

No

Yes

No

Cancer

Epilepsy / Seizures

Tuberculosis

Impaired Mobility

Asthma

Severe Hearing Loss

Hepatitis

Severe Visual Impairment

Chronic Cough

Severe Motion Sickness

Severe Depression

Fainting / Loss of Consciousness

Untreated Dental Issues

Recent unexplained weight gain > 20 lbs

Currently Pregnant

Recent unexplained weight loss > 20 lbs

Explain any positive response(s) below.

Section IV: Cardiac Screening
Indicate any cardiac condition experienced during adulthood and the applicable test result.
Yes

No

Yes

No

Abnormal EKG
Heart Attack

Hypertension
___________

Shortness of Breath
Chest Pain

Recent Blood Pressure Reading
Diabetes

__________

Recent HbA1c Reading

Explain any positive response(s) below.

Section V: Immunization Screening
Indicate the applicable test result and the dates for the following screening and immunization;
1.

Tuberculosis (TB): A tuberculosis skin test or TST (purified protein derivative, PPD), a QuantiFERON-TB blood test, or a TSpot blood test is required within the 12 months preceding the project or cruise end date. Results are documented on the
“NF 57-10-02 - Tuberculosis Screening Document” and this document must be submitted with the NHSQ along with an
actual copy of the test results for medical clearance to embark.

2.

Tetanus booster

Date _____________

NOAA Form 57-10-01
( -1 ) Page 4 of 5

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

HEALTH SERVICES QUESTIONNAIRE
Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Section VI: Functional Abilities Screening
Indicate the ability to perform the following tasks.
Yes

No
Step over a 24 inch high door sill
Walk on a steel deck for 4-8 hours per day
Stand on a steel deck for 4-8 hours per day
Walk on slippery or uneven walking surfaces
Climb stairs
Carry 15 lbs
Don a survival suit in less than one (1) minute
Ascend a rope ladder with rigid rungs
Descend a rope ladder with rigid rungs
Hear a ship’s general alarm (hearing aid permitted)

Explain any
response(s) below and indicate any medical condition or physical limitation which may adversely affect
qualification for sea duty.

Section VII: Applicant Certification
I certify the information provided is true, accurate, and complete to the best of my knowledge. I acknowledge that falsification
of any information on this government document is punishable by fine, imprisonment, or both.

Applicant Signature

For assistance completing this form, contact;
1.
MOC-A Health Services in Norfolk, VA

Date

Phone:(757) 441-6320

Fax: (757) 441-3760

MOC Health Services Use Only
Applicant is medically cleared for sea duty aboard a NOAA ship by history.
Applicant is medically disqualified for sea duty aboard a NOAA ship by history.
Additional information is needed to determine medical clearance for sea duty.

MOC Health Services Medical Officer Signature

Date

NOAA Form 57-10-01
( -1 ) Page 5 of 5

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

HEALTH SERVICES QUESTIONNAIRE
Application for Medical Qualification to Embark a NOAA Ship
Applicant Name (Last, First Middle)

Today’s Date

Continuation Page
Use the space provided below to further explain any medical condition indicated on the previous pages.

SUPERSEDES NOAA Form 57-10-01 (12-11)

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NOAA Form 57-10-02
(1-14) Page 1 of 2

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

TUBERCULOSIS SCREENING DOCUMENT
This form must be used to document the annual tuberculosis screening required by NOAA Policy 1008 of all persons seeking medical clearance by
NOAA Health Services to sail on a NOAA ship.
NAME

YEAR OF BIRTH

DATE

SECTION 1: To be completed by the healthcare professional performing the tuberculosis testing.

TST TEST RESULTS
DATE GIVEN

QUANTIFERON GOLD OR T-SPOT RESULT
(COPY OF RESULTS MUST BE INCLUDED)
DATE TEST OBTAINED
TEST OBTAINED

DATE READ

_______QFT-G
RESULT

INTERPRETATION

TEST RESULT

______ (mm induration)

______ POSITIVE
______ NEGATIVE
PROVIDER SIGNATURE
DATE

NEGATIVE
PROVIDER NAME (PRINT

PROVIDER NAME (PRINT)

________T-SPOT

POSITIVE
INDETERMINATE/BORDERLINE
PROVIDER SIGNATURE
DATE

SECTION 2: To be completed ONLY if you had positive results in Section 1 or have a history of a positive TST test or positive/indeterminate
Quantiferon Gold or T-Spot blood test.

Please consider the following questions: (mark the appropriate answer)
1. Have you ever had a positive TB skin Test?
2. Date of your last chest x-ray (if applicable)

NO

YES If yes, when ________

___________________

3. Date of BGG Vaccine (if applicable) ________________
4. Date you completed your prescribed medications to treat your positive TB Test (if applicable) ______________
5. Have you ever lived with or been in close contact with anyone who had TB disease?

NO

YES

6. Have you ever had a positive HIV test?

NO

YES

7. Have you ever used illegal intravenous drugs?

NO

YES

8. Are you currently taking steroids, chemotherapy, or cancer treating drugs?

NO

YES

9. Have you ever been incarcerated?

NO

YES

10. Have you ever been homeless?

NO

YES

11. Do you currently have any of the following symptoms? (check if YES)
___ Fever

___Weight Loss

___ Night Sweats

___ Chronic Cough

___ Chronic Fatigue

___ Coughing up blood

12. Consider the following list of high burden countries that account for 80% of new TB cases each year:
Afghanistan
Myanmar
Indonesia

DR Congo
South Africa
Pakistan

Mozambique
Zimbabwe
Uganda

Brazil
China
India

Kenya
Vietnam
Nigeria

Philippines
Bangladesh
Thailand

UR Tanzania
Ethiopia
Cambodia
Russian Federation

Were you born in one of the countries listed above?

NO

YES

Have you ever stayed/lived in one of these countries for one month or longer?
Have you ever lived or been in close contact with someone who stayed/lived in one of
these countries for one month or longer?

NO

YES

NO

YES

NOAA Form 57-10-02
(1-14) Page 2 of 2

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

TUBERCULOSIS SCREENING DOCUMENT
I certify that I have reviewed the foregoing information supplied by me and that it is true and complete to the best of my
knowledge. I authorize any of the doctors, hospitals, or clinics mentioned above to furnish the Government a complete
transcript of my medical record for purposes of processing my application for this employment or service. I understand
that falsification of information on Government forms is punishable by fine and/or imprisonment.
SIGNATURE

SIGNATURE DATE

SECTION 3: If you completed Section 2, you must obtain a physical examination from your medical provider. Your medical provider must complete
this section. All associated medical records must be sent to NOAA Health Services.

NOAA policy requires that all persons with a recent or remote positive test for exposure to the tuberculosis bacteria
must obtain an annual physical examination by a licensed medical provider (physician, nurse practitioner, or physician
assistant) to determine if latent TB infection or active disease is present, and if persons with latent infection are at high
risk for developing active disease. This annual examination must include interpretation of a chest x-ray less than 5 years
old. Center for Disease Control and Prevention (CDC) Guidelines and NOAA Health Services policy require persons with
latent infections who are at high risk of developing active disease to initiate prophylactic treatment before obtaining
medical clearance from NOAA Health Services to sail on a NOAA ship.
I have examined this patient following the NOAA Medical Policy and determined this patient has:
Latent TB infection with low risk of developing active disease.
Latent TB infection with high risk of developing active disease.
Prophylactic Medication/s Prescribed: ______________________________________________________
Date Prophylactic Medication began _________
Date Prophylactic Medication will be completed _________

Active Tuberculosis.
PROVIDER CONTACT INFORMATION (ADDRESS)

PROVIDER CONTACT TELEPHONE NUMBER

PROVIDER TITLE

DATE OF EXAMINATION

PROVIDER PRINTED NAME

PROVIDER SIGNATURE

SUPERSEDES NOAA Form 57-10-02 (4-12)

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