NF 57-03-54 Report of Medical History - Annual Update

What: This form is used to report CHANGES in the medical history of all NOAA Divers on an annual basis. The form is to be completed and signed by the NOAA Diver. 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. It is important to note that this form is for reporting CHANGES in medical status, not listing ongoing or past conditions. For example if the diver had an ear infection three years ago which required medical treatment and was reported to the NDMO at the time, it should not be included on the current year’s form.

When: This form is submitted to the NDMO by NOAA Divers each year in the same month as their current Dive Physical (NF 57-03-50, NF 57-03-51, NF 57-03-52) was submitted. 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.