NF 57-03-50, 51, 52 Report of Physical Examination

What: These three forms are used to report a diver’s health status to the NDMO. One form (NF 57-03-50) is a checklist to ensure all the required tests have been conducted and the reports included in the submission packet. The second form (NF 57-03-51) is a self-reported medical history consisting of a series of yes/no responses concerning numerous medical conditions (explanations required for affirmative responses). The third form (NF 57-03-52) is to be completed by the medical professional conducting the physical examination. It consists of basic vital signs, a general clinical exam, a neurological exam, laboratory exams and explanations of any abnormalities.

When: These forms are submitted to the NDMO by diver candidates before participating in any NOAA Diving Program training and by current NOAA Divers on a periodic basis based upon age:

• For divers under the age of 47, the exam is due every 5 years.
• For divers age 48, the exam is due in 4 years (at age 52).
• For divers age 49, the exam is due in 3 years (at age 52).
• For divers age 50 – 59, the exam is due every 2 years.
• For divers age 60 and over, the exam is due annually.

These forms contain Personally Identifiable Information (PII) and are covered under the Health Insurance Portability and Accountability Act (HIPAA), therefore transmittal to the NDMO should be done using a secure file transfer program, such as Accellion, or the NDMO fax line, (206) 529-2759.

Record keeping: None at the Diving Unit level.