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NF 57-03-53 (7-12) Report of Medical History - Observer Diver

What: This form is used to report an Observer Diver candidate’s health status to the NDMO. The form is to be completed by the Observer Diver candidate and signed by the medical professional conducting the medical review. It consists of contact information for the diver, medications, allergies, and a short medical history (yes/no list of medical conditions). There is a section for the explanation of affirmative answers in the history section.

When: This form is submitted to the NDMO by Observer Diver candidates before participating in any NOAA Diving Program operations. This form contains Personally Identifiable Information (PII) and is covered under the Health Insurance Portability and Accountability Act (HIPAA), transmittal to the NDMO should be done using a secure file transfer program, such as Accellion, or the DNMO fax line, (206) 529-2759.

Record keeping: None at the Dive Unit level.


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