SIO QUESTIONNAIRE ON PHYSICAL ABILITY FOR WORK AT SEA

Prospective members of most scientific parties on SIO research vessels, except for STS personnel assigned to the cruise, are required to complete this form. Its purpose is to obtain information, which the chief scientist and captain can use to assess:
1. Your physical ability to work at sea
2. The likelihood that any medical condition you may have might precipitate an emergency in which the ship would be forced to abandon planned work in order to seek medical assistance for you.

The questions asked focus on these two points, and there is no attempt or intent to require personal medical information unrelated to them.

Certain cruises, generally those which operate very close to shore or for which rapid medical evacuation to shore is clearly feasible, may be exempted from these required forms by the Associate Director, SIO (Ship Operations and Marine Technical Support). If you believe that you are being asked to return the form for a cruise which is exempt, ask your chief scientist to check with the Ship Scheduling Office or do so yourself.

The completed form should be signed and returned to the chief scientist - NOT to the Ship Scheduling Office or the Marine Facility - not later than 2 weeks prior to sailing, and sooner if the chief scientist has established an earlier deadline. The deadline is designed to allow orderly pre-departure review of the information by the captain and chief scientist; they and the Marine Superintendent, who sometimes assists on behalf of captains who are in remote locations, are the only individuals authorized to review the form. The captain will retain the form in a confidential file at sea and will destroy it when you leave the ship, unless you ask to have it returned. You may want to keep it or a personal copy of it in order to resubmit, with any necessary updates, for a subsequent cruise.

Some of the questions will strike "old hands" as curious. Experience shows, however, that newcomers to seagoing sometimes fail to appreciate the risks involved and the full consequences of separation from complete medical facilities ashore. Certain questions are designed to heighten the respondent's awareness of these matters.

Ultimately it is within the captain's authority to accept or reject a scientific party member on medical grounds related to safety at sea, and it is within the chief scientist's authority to accept or reject in order not to run an unreasonable risk of a medically forced diversion from the planned scientific program. These responsibilities hold whether or not a form reveals the medical abnormality under consideration. Any controversies about such rejections are referred to the Associate Director, SIO (Ship Operations) for settlement. In the final analysis individuals must take responsibility for their own safety. If you are not physically capable of work at sea, don't go.

For further information or questions, please contact:

Ship Scheduling Office
Scripps Institution of Oceanography, 0210
UCSD
9500 Gilman Dr.
La Jolla, CA 92093-0210

858-534-2840 (phone)
858-822-5811 (fax)
shipsked@ucsd.edu

SIO QUESTIONNAIRE ON PHYSICAL ABILITY FOR WORK AT SEA

__________________________ ___________________________ _____________________

Print Name Signature Date

Return to Chief Scientist _____________________________ Ship Name _______________

1. Do you use any medicines regularly? If "yes" be sure that the chief scientist or captain is aware of where they are stored, and rules for dosage and administration if you are incapacitated. Also ensure that you have sufficient supply for the entire trip plus a liberal allowance for possible delays. _______(Y/N)

2. Do you have any medical conditions which might suddenly flare up and require prompt administration of special medications or other therapies: e.g., diabetes, heart problems, ulcers, asthma, etc? ______(Y/N) If "yes", please describe:

3. Do you have any condition, which might lead to sudden unconsciousness or loss of motor control or normal coordination: e.g., fainting spells, epilepsy? If "yes", please describe: _____(Y/N)

4. Do you have any impairments of normal coordination and agility: e.g., artificial limb, partial paralysis? If "yes", please describe: _____(Y/N)

5. Do you have any uncorrectable impairments of normal sensory perception (sight, hearing, etc.)? If "yes", please describe: _____(Y/N)

6. Do you have any serious communicable diseases? If "yes", please describe: _____(Y/N)

7. Have you received any medical advice, pertinent to the time you are scheduled to be at sea, to the effect that you should not travel far away from full medical care facilities? If "yes", please describe: _____(Y/N)

8. Do you have enough experience at sea to know if you are subject to chronic seasickness? _____(Y/N)

If "yes", are you subject to chronic seasickness to an extent that may threaten your health and/or impair your ability to complete your planned tasks? _____(Y/N)

9. Have you had, or will you obtain before embarking, all of the vaccinations required* for entry into any foreign countries in which the ship will call while you are aboard or through which you will travel in the course of joining and leaving the ship? _____(Y/N)

* Information about vaccination requirements maybe obtained from travel agents, U.S. Public Health Service, and private physicians.

10. Do you have any medical condition not noted in 1-9 above which has significant likelihood either of causing an emergency** situation at sea or of rendering you unable to do your work? _____(Y/N) If "yes", please describe:

** An "emergency situation" means that in order to safeguard your health the ship must divert from its planned operations to seek medical help beyond that which can be provided from the limited facilities aboard.

11. Do you have any medical concerns, pieces of personal medical history, or other medical information, which you would like to bring to the attention of the chief scientist or captain in the interest of safeguarding your own health? If “yes", please attach an explanation or contact them in person. _____(Y/N)

12. Best wishes for a safe and productive time at sea.

The following information is voluntary:

Emergency Contact ______________________________ Telephone No. _________________

This emergency contact information may also be filled out on line on the World Wide Web at http://shipsked.ucsd.edu/general/forms/contactinfo.cfm. This information is private and confidential and available only to specific shore administration in case of emergency.