Oceanography Research Medical Clearance Form
Please complete this form to assess your medical fitness for participation in oceanography research activities.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any of the following medical conditions? (Check all that apply)
*
Asthma
Heart Disease
Diabetes
Epilepsy/Seizure Disorder
High Blood Pressure
None of the above
Other
Please list any allergies (including medication, food, or environmental):
*
Please list any current medications you are taking:
*
Have you had any recent illnesses, surgeries, or hospitalizations in the past year? If yes, please describe:
*
Physician's Assessment: Is the participant medically fit to participate in oceanography research activities (including boat travel, exposure to marine environments, and moderate physical activity)?
*
Yes, medically fit
No, not medically fit
Physician's Name
*
Physician's Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physician's Email Address
*
example@example.com
Participant or Physician Signature
*
Submit Medical Clearance
Submit Medical Clearance
Should be Empty: