NOAA Health Services Questionnaire

OMB CONTROL NO. 0648-0283
Expiration Date: 06/30/2013
OMAO NHSQ Medical form
PAPERWORK REDUCTION ACT INFORMATION
NOAA conducts the Teacher at Sea Program in order to promote oceanographic and related education.
The information obtained from the application will be used to select the teachers who will be accepted
for participation in the program, and an application is required for acceptance. Once selected, the
teacher will complete an OMAO NHSQ medical form. The information submitted on this form will be
treated confidentially. Public reporting burden for this collection of information is estimated to average
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 collection of information.
Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing this burden, to NOAA’s Teacher at Sea Program, 1315 East West Hwy,
Division F, Silver Spring, MD 20910 Notwithstanding any other provision of the law, no person is
required to respond to, nor shall any person be subject to a penalty for failure to comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that
collection displays a currently valid OMB Control Number.

U.S. Department of Commerce
National Oceanic and Atmospheric Administration
Office of Marine and Aviation Operations

INSTRUCTIONS FOR COMPLETING THE NOAA HEALTH SERVICES QUESTIONNAIRE
(NHSQ, Revised 08/08, Implementation date 01/01/09)
Please print clearly if you are not submitting this form electronically. Make sure your name appears at
the top of each page. Fill out ALL questions completely to avoid a delay in processing.
Any questions answered “yes” on this form will require further explanation in the space provided. If
additional space is needed, please use page 4 of the form. If you answered “yes” to hypertension or
diabetes in the “Cardiac Screening” section, you must provide the most recent blood pressure or HbA1c
reading.
In the Immunization Screening section, everyone who sails on a NOAA vessel must have a test for
tuberculosis (TB) within the last 12 months. There are two tests that NOAA accepts to detect exposure
to the TB germ: the PPD (or TB skin test) or the Quantiferon test (a blood
test). If you have a PPD test done for TB, the results must be recorded in
millimeters only. PPD tests are not read as positive or negative. The
Quantiferon test is a blood test as is read as negative, positive, or
indeterminate.
The Functional Abilities Screening section makes reference to a survival suit
and a rope ladder. More detailed information can be found on these items by
typing “survival suit” and “rope ladder” in to any internet search engine.
An adult survival suit is often a large bulky one-size-fits-all design meant to fit
a wide range of sizes. It is made of neoprene and typically has large oversize
booties and gloves built into the suit. This allows the user to quickly don it on
while fully clothed and without having to remove shoes. It typically has a
waterproof zipper up the front, and a face flap to seal water out around the
neck and protect the wearer from ocean spray. In the event of an
emergency, it should be possible to put on a survival suit and abandon ship in
about one minute.
A rope ladder is a flexible ladder made by attaching rope to both ends of
wooden rungs. It hangs down over the side of the ship and is used to enter a
small boat or to get back on the ship’s deck from a small boat. The rope
ladder is anchored to the ship at one end but the other end hangs freely and is
not attached. A free hanging rope ladder is more difficult to climb than one
that is firmly moored at the bottom.
Sign and date this form near the bottom of page 3. Do not write in the NOAA
Health Services Use Only section. Use page 4 to provide any additional
information.

Revised: 08/08
Effective date: 01/01/09

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 below:

Please list ALL the medications that you currently take (prescription and non-prescription):
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. __________________________________________________________

Reset form

Revised: 08/08
Effective date: 01/01/09

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
___ ___
___ ___
___ ___
___ ___
Explain:

Abnormal EKG
Heart attack
Shortness of breath
Chest pain

No
___

Yes
___

___

___

Hypertension
Recent BP reading: ________
Diabetes
Recent HgA1C: ___________

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: ________

Revised: 08/08
Effective date: 01/01/09

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
___
___
___
___
___
___
___
___

___
Explain:

___

Walking on steel decks for hours
Standing on steel decks for hours
Step over 24 inch high door sill
Climbing stairs
Carry survival suit (<15 pounds) up/down stairs
Don an survival 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

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)441-3760, 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

___ Need more info
____________
Date

Revised: 08/08
Effective date: 01/01/09

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.