Human Test Subject Facility

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Research Participant must be a US citizen or permanent resident to meet the NASA/Johnson Space Center Security requirements to be considered as a potential test subject. You must also meet the Modified Air Force Class III Medical Standard. NASA has determined that all persons who are selected and/or assigned to participate in human subject testing should have initial blood tests as part of the recruitment procedure and physical exam. By providing answers to these medical questions, you begin the screening and eligibility process. We are looking for a population that resembles the NASA astronaut population. If you have any questions regarding the application process, you may leave your contact information by calling 1-866-JSC-TEST.

Personal Information

First Name:

Middle Name:

Last Name:

Street Address:

City & State:

Zip Code: -

Sex:MaleFemale

Height:ft. in.

Weight:lbs.

Date of Birth:

Primary Phone:

Secondary Phone:

Email Address:

Occupation:

Smoking History:

Do you live within 300 miles of Houston: YesNo

Willing to consent to a modified Air Force Class III physical: YesNo

Willing to consent to criminal background check: YesNo

Willing to consent to an infectious disease screening: YesNo

Have you ever been convicted of a felony: YesNo

Willing to consent to drug and alcohol screen: YesNo

Read and agree to Privacy Act Statement:

Medical Information

Do you have a history of:

Diabetes: YesNo/Don't Know

High blood pressure: YesNo/Don't Know

Heart trouble: YesNo/Don't Know

Back surgery: YesNo/Don't Know

Mental Illness: YesNo/Don't Know

Kidney Stones: YesNo/Don't Know

Gastric reflux: YesNo/Don't Know

Sleep walking: YesNo/Don't Know

Cancer: YesNo/Don't Know

Asthma or breathing problems: YesNo/Don't Know

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NASA \| Johnson Space Center \| Exploration Systems Mission Directorate \| Human System Research & Technology
	+ Space Life Sciences Directorate + Human Adaptation and Countermeasures Division	Editor: Julie Campos NASA Official: Todd Schlegel, MD Last Updated: March 14, 2006 + Contact HTSF + Web Accessibility and Policy Notices + Privacy Policy and Important Notices