**Form Approved**

**OMB# 0648-0547**

**Expires: 09/30/2009**

**NOAA Health Services Aviation Questionnaire**

(This information is for official and medically confidential use only
and will only be released to NOAA medical personnel)

**PAPERWORK REDUCTION ACT STATEMENT**

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
suggestions for reducing this burden to Health Services, NOAA Office of
Marine and Aviation Operations 8403 Colesville Rd., Silver Spring, MD
20910-1282. Notwithstanding any other provisions of the law, no person
is required to respond to, nor shall any person be subjected to a
penalty for failure to comply with, a collection of information subject
to the requirements of the Paperwork Reduction Act, unless that
collection of information displays a currently valid OMB Control Number.

**PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. SUBMIT
COMPLETED FORM AS INDICATED ON PAGE 2.**

**PRINCIPAL PURPOSE(S)** To obtain medical data for determination of
medical fitness for flight aboard aircraft flying Mission Operations on
behalf of NOAA to screen and identify individuals that could be placed
in a work environment (flight) with the potential to aggravated existing
medical conditions.

DISCLOSURE: Voluntary; however, failure by an applicant to provide the
information may result in denial of a NOAA Aeromedical Clearance Notice
which is

required to fly Mission Operations aboard aircraft operated by NOAA as
well as aircraft operated by other entities on behalf of NOAA with NOAA
personnel on board.

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**Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Your E-Mail:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Last First Your Phone:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**SSN:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Birth Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Sex: \_\_\_\_\_
\_\_\_\_\_ NOAA Program:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**(mm/dd/yr) M F NOAA Supervisor:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**NOAA Supervisor E-Mail: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Your Phone Numbers: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (W)
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ (H)**

**Emergency Contact:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Name Phone Relationship**

**GENERAL MEDICAL SCREENING**

**YES NO Do you have, or have you ever had: (explain any positive
responses on Continuation Page)**

1.  **Disease of the eyes, ears, sinuses, seasonal allergies, hayfever,
    difficulty with clearing your ears, severe hearing loss, or pain in
    your ears or sinuses from diving or flying?**

2.  **Chest pain, angina, heart attack, heart disease, heart murmur,
    palpitations, cardiac catheterizations, or pacemaker?**

3.  **Hypertension, stroke, blood clots in legs, swelling in feet, or
    excessive fatigue with mild exertion?**

4.  **Asthma, wheezing, emphysema, chronic cough, tuberculosis,
    collapsed lung, or shortness of breath with mild exertion?**

5.  **Diseases of the bowel, ulcers, rectal bleeding, chronic abdominal
    pain, hernia, kidney stone, or painful or frequent urination?**

6.  **Arthritis, joint deformity, chronic back pain, or limitation of
    use of your back or extremities?**

7.  **Paralysis, weakness of muscles, seizures, epilepsy, migraine or
    other severe headaches, loss of consciousness, fainting spells,
    dizziness, or amnesia?**

8.  **Mania, depression, schizophrenia, suicide attempt, alcoholism,
    illegal drug use, panic attacks, fear of flying, fear of heights, or
    fear of enclosed spaces?**

9.  **Anemia, diabetes, cancer(s), arterial gas embolism, decompression
    sickness, severe motion sickness, surgery, hospitalization, or other
    chronic medical conditions not listed?**

10. **Are you currently pregnant?**

11. **Are you currently taking any medications?**

**List Current Medications: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**\*\*\*If you have been scuba diving within 24 hours of flying, have
had any dental procedures within 48 hours of flying, or are currently
pregnant -- YOU MUST CONSULT WITH A FLIGHT SURGEON.**

**Are you aware of any other medical condition(s) that may affect your
suitability for aviation duty? No Yes**

If yes, please explain on the continuation page

If you have any questions, please contact the appropriate Health
Services Office:

**Aircraft Operations Center: 813-828-3310 x-3102 (Office) /
813-294-6703 (Cellular)**

**Marine Operations Atlantic: 757-441-6320 (Office) / 757-615-6619
(Cellular)**

**Marine Operations Pacific: 206-553-8704 (Office) / 206-409-8725
(Cellular)**

**Director, NMAO Health Services: 301-713-7715 (Office) / 240-478-8915
(Cellular)**

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
understand that falsification of information on Government forms is
punishable by fine and/or imprisonment. **[ANY CHANGES IN YOUR MEDICAL
CONDITION SINCE YOU LAST COMPLETED THIS MEDICAL HISTORY FORM, MUST BE
REPORTED TO THE NOAA AVIATION MEDICAL EXAMINER
IMMEDIATELY]{.underline}.**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Employee Signature Date (mm/dd/yy)

**Please submit your completed questionnaire to one of the following
offices for review:**

NOAA AIRCRAFT OPERATIONS CENTER NOAA DIVE CENTER

NOAA OFFICE OF HEALTH SERVICES NOAA OFFICE OF HEALTH SERVICES

P.O. BOX 6829 7600 SAND POINT WAY, NE

MACDILL AIR FORCE BASE, FL 33608-0829 SEATTLE, WA 98115

Secure fax (813-828-5060 Secure fax (206) 526-6506

**\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
\[Below section to be completed by NOAA Medical Officer\]
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--**

**MEDICALLY CLEARED FOR AVIATION DUTY BY HISTORY: YES NO NEED MORE
INFO**

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

AOC / MOA / MOP Regional Director of Health Services Date (mm/dd/yy)

**Page \_\_\_ of \_\_\_** Name:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**NOAA Health Services Aviation Questionnaire Continuation Page**