Form NF 57-10-01 NF 57-10-01 NOAA Health Services Questionnaire

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 1 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE

Section I: Applicant Information
Applicant Name
(Last, First, Middle)
Office, Laboratory,
or Institution Name
Work Address

Date of Birth
Cell Phone
Work Phone

City

State

Zip Code

E-mail Address

Home Phone
**Check one preferred contact
phone number above. **

Emergency Contact
Name
Address
Project Dates

Today’s Date

City

Relationship

Cell Phone

State/Zip Code

Home Phone

Start

End

Project Ship(s)

☐ Scientist
☐ Contractor
☐ Other (specify below)
________________________
☐ Teacher at Sea
☐ Volunteer
Have you sailed with NOAA before? ☐ Yes
☐ No
If yes, list sail date(s) and ship(s) below?
Dates
Ship
Section II: Current Health Information (Provide additional information on page 4 if needed.)
Position

List all health problems/medical conditions.

None

1.
2.
3.
4.

5.
6.
7.
8.

1.
2.
3.
4.

5.
6.
7.
8.

List all medications (prescription and non-prescription) you currently take.

None

List major surgeries, hospitalizations, and emergency room visits.

1.
2.

None

Allergies

1. Do you have any medication, food (e.g., peanut, tree nut, shellfish, or egg), or contact (e.g., latex) allergies?

☐

Yes

☐ No

2. Do you carry an EpiPen and/or have you received treatment for anaphylaxis?

☐ Yes

☐ No

Note: The applicant is required to bring their personal EpiPen with them when they report to the ship.

1.
2.
3.
4.

List All Allergies

1.
2.
3.
4.

List Symptoms or Reactions

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 2 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE
Today’s Date

Applicant Name
(Last, First, Middle)

Section III: General Screening
Indicate any past or current medical condition.
Yes

No

Yes

No

Tuberculosis

Epilepsy/Seizure Disorder

Asthma

Impaired Mobility

Hepatitis

Severe Hearing Loss

Chronic Cough

Severe Visual Impairment

Depression

Severe Motion Sickness

Untreated Dental Issues

Fainting/Loss of Consciousness

Currently Pregnant

Unexplained Weight Loss >20 lbs

Muscle/Joint Conditions (e.g.,
back hip, knee)

Unexplained Weight Gain >20 lbs

Explain any positive response(s) below.

Section IV: Cardiac Screening
Indicate any cardiac condition experienced and the applicable test result.
Yes
Yes
No
No
Abnormal EKG
Pacemaker or AICD
(implantable defibrillator)
Heart Disease (e.g., chest pain, blood
vessel disease, irregular heartbeat,
congenital heart defect, heart valve or
muscle disease, heart attack)

Shortness of Breath
Hypertension (list recent reading

below)

Diabetes (list recent HbA1C reading

below)

Explain any positive response(s) below.

Section V: Required Immunizations
All items below are required in order to be cleared for sailing.
1. MMR vaccination **Persons born before 1957 are exempt.** Date(s) Completed _______________
_______________
2. Tetanus diphtheria (or tetanus, diphtheria,
acellular pertussis) booster

Date Completed _______________
(Must be within the last 10 years).

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 3 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE
Today’s Date

Applicant Name
(Last, First, Middle)

Section VI: Functional Capacity 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

☐

Walk on slippery or uneven walking surfaces

☐
☐
☐
☐
☐
☐

Stand on a steel deck for 4–8 hours per day
Climb stairs
Carry 15 lbs
Don an immersion suit in less than 2 minutes
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 negative response(s) below, and indicate any medical or physical limitation that may
adversely affect functional capacity.

Section VII: Applicant Certification
I certify the information provided is true, accurate, and complete to the best of my knowledge.

Applicant’s Signature
For assistance completing this form, contact:
1.
MOC-A Health Services in Norfolk, VA
2.
MOC-P Health Services in Newport, OR
MOC Health Services Use Only

Date
Phone: (757) 441-6320
Phone: (541) 351-4696

Fax: (757) 441-3760
Fax: (541) 351-4732

☐ Applicant is medically qualified for sea duty aboard a NOAA ship.

☐ Applicant is medically disqualified for sea duty aboard a NOAA ship.

☐ Additional information is needed to determine medical qualification for sea duty.
MOC Health Services Medical Officer’s Signature

Date

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 4 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE

Applicant Name
(Last, First, Middle)

Additional Comments
Use the space provided below to further explain any items on the previous pages.

Medical Officer Comments

_____ Request for Additional Information (RAI) sent.

Today’s Date

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 5 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE
INSTRUCTIONS

The NOAA Health Services Questionnaire must be submitted to MOC Health Services 30 days in
advance of the project start date. The form must be legible and complete. Unreadable or incomplete
forms will be returned to the applicant. Late submissions may result in delayed qualification of sea
duty past the project start date.
All positive responses in the General Screening and Cardiac Screening sections require a detailed
explanation in the space provided. The Additional Comments Page 4 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 complete the Annual Tuberculosis Screening form
(NF 57-10-02) within the 12 months preceding the project end date. MOC Health Services will notify
you if you require one of the three tests to detect exposure to the TB: the Purified Protein
Derivative (PPD or TB skin test), the QuantiFERON-TB test (QFT or TB blood test), or 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.
Any person who sails aboard a NOAA ship must be able to perform normal daily work functions.
In addition, anyone who sails aboard a NOAA ship must be able to perform minimal personal safety
and emergency response functions while the ship is underway. During an abandon ship event,
personnel may be required 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 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 is a full-body singlepiece coverall designed to provide thermal protection to personnel immersed in water. A person
at sea should be able to don a survival suit in two minutes while fully clothed and without having
to remove shoes. You will be trained on how to put on this suit before you sail as part of the safety
brief.
Any negative responses in the Functional Capacity Screening section require further explanation on the
Additional Comments Page 4.
Sign and date the form in Section VII. Do not write in the “MOC Health Services Use Only” section.
Use the Additional Comments Page 4 to provide any additional information.
Please direct all questions regarding the information required on this form to the MOC Health Services
at MOC-A (757) 441-6320 or MOC-P (541) 867-8820.

NOAA Form 57-10-01 (01-25)
OMB Control No. 0648-0824
Expiration Date 06-30-2027
Page 6 of 6

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

NOAA HEALTH SERVICES QUESTIONNAIRE

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 0648-0824. Without this
approval, we could not conduct this information collection. Public reporting for this information collection is estimated to be approximately 15
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 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 Office of Marine and Aviation Operations, 1315 East West Hwy, Silver Spring, MD 20910.

Privacy Act Statement
Authorities: Privacy Act of 1974, 5 CFR Part 293, Personnel Records and Part 297, Privacy Procedures for Personnel Records; Occupational
Safety and Health Administration, 29 CFR 1910, Occupational Safety and Health Standards, Health Insurance Portability and Accountability Act,
Pub. L. 104-191.
Purposes: The health services you receive through this program result in the gathering and recording of information that is personal and
confidential. Your employing agency serves as a custodian of your records. Upon termination of employment the original documents or copies
of your records will be transferred to your Employee Medical Folder (EMF) in the agency’s Employee Medical File System (EMFS). These records
are stored as a distinct and separate part of your Official Personnel Folder. Your records are collected and maintained for a variety of purposes,
including:
•
•
•
•
•
•
•
•
•
•
•

to meet the mandates of law, Executive order, or regulations;
to provide data necessary for proper medical evaluations, treatment for the continuity of medical care;
to provide an accurate medical history and treatment and/or hazard exposures and health monitoring;
to enable the planning for further care;
to provide a record of communications among members of the health care team;
to provide a legal document describing the health care administered and exposure incidents;
to provide a method of evaluating the quality of health care rendered as required by professional standards and legislative authority;
to ensure that all relevant, necessary, accurate, and timely data are available to support any medically related employment decisions;
to document claims filed with and the decisions reached in OWCP cases;
to document employee's reporting of occupational injuries, unhealthy and/or unsafe working conditions;
to ensure proper and accurate operation of the agency's employee drug testing program under Executive Order 12564.

Routine Uses: Information is collected to manage medical care and to maintain accurate and current medical records on employees. Disclosure
of this information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a), to be shared with applicable entities related to the
purposes described above. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act
System of Records Notice, COMMERCE/NOAA–22, NOAA Health Services Questionnaire (NHSQ) and Tuberculosis Screening Document (TSD).
Disclosure: Collection of this information is voluntary. If you do not wish to participate in these services, or to provide the requested
information, you are not required to do so. Non-NOAA personnel may decline to provide this information, but the absence of documented
medical clearances may prevent you from being cleared to embark on NOAA vessels or aircraft. For NOAA personnel choosing to decline the
health services required for job-related clearances, the absence of documented medical clearances in will impact the employer’s authority to
permit you to perform certain functions of your position. You should consult with your supervisor in this matter.