NOAA Health Services Questionnaire

Revised 8/08

Page 1 of 4

NOAA HEALTH SERVICES QUESTIONNAIRE
(NO nicknames)

Name (print): _____________________________________ Birth Year: ___________
Last
First
Middle
Work Address: ________________________________ Work Phone: ____________
________________________________ Cell Phone: _____________
________________________________ Home Phone: ____________
E-mail Address: _______________________________
Preferred contact number:
___ Work
___ Cell
___ Home
Current position: ___ Scientist ___ Teacher-at-Sea ___Volunteer Contractor
___ Other: (specify) _______________________________________
Emergency contact: ___________________________ Relationship: ______________
Address: ____________________________________ Phone: __________________
____________________________________
Cruise dates: ___________________________________________________________
Forward to the following ships: _____________________________________________
Health Information
Supply additional information on last page of this form if needed.
At the present time, do you regularly see a doctor for any reason? ___ No
___ Yes
If yes, explain: _______________________________________________________
___________________________________________________________________________________

Please list ALL the medications that you currently take (prescription and nonprescription):
1. __________________________
4. __________________________
None ___ 2. __________________________
5. __________________________
3. __________________________
6. __________________________
List any known allergy: Allergy
1. ______________________
None ___ 2. ______________________
3. ______________________

Reaction
_________________________________
_________________________________
_________________________________

List ALL current health problems/conditions (even if you are not taking medication for
them):
1. __________________________________________________________
None ___ 2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________
List major surgeries/hospitalizations/emergency room visits:
1. __________________________________________________________
None ___ 2. __________________________________________________________
3. __________________________________________________________
4. __________________________________________________________
OMB Control No. 0648-0283

Expires 06/30/2010

Revised 8/08

Page 2 of 4

Name: ___________________________________________
Last
First
Middle

General Screening
As an adult, have you had or currently have any of the following:
No
___
___
___
___
___
___
___
___

Yes
___
___
___
___
___
___
___
___

Cancer
Tuberculosis
Asthma
Hepatitis
Chronic cough
Severe depression
Are you pregnant?
Untreated dental issues

No
___
___
___
___
___
___
___

Yes
___
___
___
___
___
___
___

Epilepsy/seizures
Impaired mobility
Severe hearing loss
Severe visual impairment
Severe motion sickness
Fainting/loss of consciousness
Recent unexplained weight
gain/loss of > 20 pounds

Explain: _______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Cardiac Screening
As an adult, have you had or currently have any of the following:
No Yes
No Yes
___ ___ Abnormal EKG
___ ___ Hypertension
___ ___ Heart attack
Recent BP reading: ________
___ ___ Shortness of breath
___ ___ Diabetes
___ ___ Chest pain
Recent HgA1C: ___________
Explain: _______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Immunization Screening
Please list the date(s) you obtained immunization/prophylaxis against:
1. TB (must have one of the following within the past 12 months; test cannot expire
before the end of the desired cruise):
a. PPD: Date: _________ Results: _________ (must be noted in millimeters only)
b. Quantiferon: Date: __________
Results (circle one):
Negative Indeterminate
Positive
2. Tetanus booster: Date: ________

OMB Control No. 0648-0283

Expires 06/30/2010

Revised 8/08

Page 3 of 4

Name: ___________________________________________
Last
First
Middle

Functional Abilities Screening
Are you able to perform the following (explain all “no” answers below)?
Yes
___
___
___
___
___
___
___
___

No
___
___
___
___
___
___
___
___

___

___

Walking on steel decks for hours
Standing on steel decks for hours
Step over 24 inch high door sill
Climbing stairs
Carry exposure suit (<15 pounds) up/down stairs
Don an exposure suit in 1 minute
Can hear alarms (hearing aid permitted)
Descend/ascend a rope ladder with rigid rungs a
distance of 10 feet
Walking on slippery, uneven, and/or moving surfaces

Explain: _______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Are you aware of any other medical condition(s) that may affect your suitability for sea
duty? ___ No ___ Yes – Explain: ________________________________________
______________________________________________________________________
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 acknowledge that
falsification of information on this government document is punishable by fine
and/or imprisonment.
_____________________________________________
Signature of Applicant

____________
Date

For assistance contact: (1) Marine Operations Atlantic at (757)441-6320, fax (757)4413760, or (2) Marine Operations Pacific at (206)553-8704, fax (206)553-1112.
NOAA HEALTH SERVICES USE ONLY
Medically cleared for sea duty by history? ___ Yes

___ No

______________________________________________
NOAA Health Services Medical Officer

OMB Control No. 0648-0283

___ Need more info
____________
Date

Expires 06/30/2010

Revised 8/08

Page 4 of 4

Name: ___________________________________________
Last
First
Middle

NOAA HEALTH SERVICES QUESTIONNAIRE
CONTINUATION PAGE
Use this space for further documentation related to questions on the previous pages.

OMB Control No. 0648-0283

Expires 06/30/2010