HERAAnalogMissionApplication
type: Questionnaire
node role: treeRoot
id:
  v: HERAAnalogMissionApplication
text:
  status:
    v: extensions
  div:
    v: Generated Narrative: Questionnaire HERAAnalogMissionApplication Structure LinkID Text Cardinality Type Description & Constraints<img src="[binary]" alt="doco" style="background-color: inherit"/> HERAAnalogMissionApplication Application for the Human Exploration Research Analog (HERA) mission at NASA Johnson Space Center Questionnaire http://example.org/Questionnaire/hera-analog-mission-application#0.5.12 #xD; intro Application for Analog Missions. Additional information regarding HERA studies at the Johnson Space Center including a video tour of the HERA facility can be found on the NASA website. Before applying to be a study participant we ask that you review this information for a better understanding of what your participation would entail if chosen as a subject for a future HERA mission. 0..1 display #xD; privacy-statement Privacy Act Statement: Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the following statement is furnished to individuals applying to become ground study subjects for the Flight Analog Project. Authority: This collection is authorized by 51 U.S.C. 20113(a) and 44 U.S.C. 3101. Purpose: We will use the information to determine eligibility for the Flight Analog Project. Effect of Nondisclosure: Supplying the information is voluntary on your part. However, failing to provide all or part of the information may prevent an accurate and timely decision on your application. 0..1 display #xD; consent By submitting this form, you consent to adding your responses to the analog subject registry. After reviewing your responses, further information may be requested. You may withdraw your information from this registry at any time by sending an e-mail to the recruitment team. 0..1 display #xD; citizenship Are you a United States citizen? 1..1 boolean #xD; confinement-consent For HERA missions, are you willing to be confined and isolated for required periods of time? 1..1 boolean #xD; confinement-details HERA mission duration includes a confined isolati…
url:
  v: http://example.org/Questionnaire/hera-analog-mission-application
  l: hera-analog-mission-application
version:
  v: 0.5.12
name:
  v: HERAAnalogMissionApplication
title:
  v: NASA HERA Analog Mission Application
status:
  v: active
subject type:
  v: Patient
date:
  v: 2025-05-18
publisher:
  v: MITRE
contact:
  name:
    v: MITRE
  telecom:
    system:
      v: url
    value:
      v: https://www.mitre.org/
description:
  v: Application for the Human Exploration Research Analog (HERA) mission at NASA Johnson Space Center
purpose:
  v: To determine eligibility for the Flight Analog Project, including initial screening and evaluation to become a ground study subject.
copyright:
  v: This information collection meets the requirements of 44 U.S.C 3507. OMB control number 2700-0174, expires 04/30/2026.
item:
  link id:
    v: intro
  text:
    v: Application for Analog Missions. Additional information regarding HERA studies at the Johnson Space Center including a video tour of the HERA facility can be found on the NASA website. Before applying to be a study participant we ask that you review this information for a better understanding of what your participation would entail if chosen as a subject for a future HERA mission.
  type:
    v: display
item:
  link id:
    v: privacy-statement
  text:
    v: Privacy Act Statement: Pursuant to the Privacy Act of 1974, 5 U.S.C. § 552a, the following statement is furnished to individuals applying to become ground study subjects for the Flight Analog Project. Authority: This collection is authorized by 51 U.S.C. 20113(a) and 44 U.S.C. 3101. Purpose: We will use the information to determine eligibility for the Flight Analog Project. Effect of Nondisclosure: Supplying the information is voluntary on your part. However, failing to provide all or part of the information may prevent an accurate and timely decision on your application.
  type:
    v: display
item:
  link id:
    v: consent
  text:
    v: By submitting this form, you consent to adding your responses to the analog subject registry. After reviewing your responses, further information may be requested. You may withdraw your information from this registry at any time by sending an e-mail to the recruitment team.
  type:
    v: display
item:
  link id:
    v: citizenship
  text:
    v: Are you a United States citizen?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: confinement-consent
  text:
    v: For HERA missions, are you willing to be confined and isolated for required periods of time?
  type:
    v: boolean
  required:
    v: true
  item:
    link id:
      v: confinement-details
    text:
      v: HERA mission duration includes a confined isolation of 45 days. In addition to the isolation phase, each mission includes 16 days of pre-mission data collection and training and 7 days of post-mission data collection, requiring a stay in Houston, TX of up to 72 days.
    type:
      v: display
item:
  link id:
    v: demographic-info
  text:
    v: Demographic Information
  type:
    v: group
  required:
    v: true
  item:
    link id:
      v: firstName
    text:
      v: First Name
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: middleName
    text:
      v: Middle Name
    type:
      v: string
  item:
    link id:
      v: lastName
    text:
      v: Last Name
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: phoneNumber
    text:
      v: Phone Number
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: emailAddress
    text:
      v: Email Address
    type:
      v: string
    required:
      v: true
  item:
    link id:
      v: confirmEmailAddress
    text:
      v: Confirm Email Address
    type:
      v: string
    required:
      v: true
item:
  link id:
    v: age-check
  text:
    v: Are you currently between the ages of 28 and 55?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: birthdate
  text:
    v: Birthdate
  type:
    v: date
  required:
    v: true
item:
  link id:
    v: sex
  text:
    v: Sex
  type:
    v: choice
  required:
    v: true
  answer option:
    value: Coding
      system:
        v: http://hl7.org/fhir/administrative-gender
        l: administrative-gender
      code:
        v: male
      display:
        v: Male
  answer option:
    value: Coding
      system:
        v: http://hl7.org/fhir/administrative-gender
        l: administrative-gender
      code:
        v: female
      display:
        v: Female
item:
  link id:
    v: height
  text:
    v: Height (in inches). For HERA missions, height not to exceed 6' 2" (74 inches)
  type:
    v: decimal
  required:
    v: true

link id:
  v: weight
text:
  v: Weight (in pounds)
type:
  v: decimal
required:
  v: true

link id:
  v: born-outside-us
text:
  v: Were you born outside of the United States?
type:
  v: boolean
required:
  v: true

link id:
  v: other-citizenship
text:
  v: Do you hold citizenship in any country other than the United States?
type:
  v: boolean
required:
  v: true

link id:
  v: tobacco-nicotine
text:
  v: Do you use any tobacco or nicotine products (select all that apply)?
type:
  v: choice
required:
  v: true
repeats:
  v: true
answer option:
  value: String
    v: None
answer option:
  value: String
    v: Smoking
answer option:
  value: String
    v: Vaping
answer option:
  value: String
    v: Chewing
answer option:
  value: String
    v: Skin Patches
answer option:
  value: String
    v: Other

link id:
  v: medical-section
text:
  v: Medical History
type:
  v: group
required:
  v: true
item:
  link id:
    v: metal-in-body
  text:
    v: Do you have any metal in your body other than dental work?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: claustrophobia
  text:
    v: Are you claustrophobic?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: allergies-gi-diet
  text:
    v: Do you have any of the following?
  type:
    v: choice
  repeats:
    v: true
  answer option:
    value: String
      v: Allergies (including food)
  answer option:
    value: String
      v: GI Disorders
  answer option:
    value: String
      v: Dietary Limitations
item:
  link id:
    v: cardiovascular
  text:
    v: Any cardiovascular or circulatory system issues?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: neurological
  text:
    v: Any neurological problems?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: musculoskeletal
  text:
    v: Any musculoskeletal problems?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: medications
  text:
    v: Are you taking any medications?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: sleep-disorders
  text:
    v: Any sleep disorders such as sleep walking or use of sleep aids?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: psychiatric
  text:
    v: Any psychiatric disorders or history of mental illness?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: motion-sickness
  text:
    v: Any motion sickness (not a disqualifier)?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: adhd-treatment
  text:
    v: Any pharmacological treatment for ADHD?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: kidney-stones
  text:
    v: Any history of kidney stones?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: ulcers
  text:
    v: Any history of ulcers?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: epilepsy
  text:
    v: Any history of epilepsy or other disorders of the brain?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: blood-clots
  text:
    v: Any history of blood clots?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: family-seizures
  text:
    v: Any history of close relatives with seizures?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: bisphosphonate
  text:
    v: Are you currently on Bis-Phosphonate (for example, Fosamax, Boniva, or Reclast)?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: seizure-meds
  text:
    v: Are you currently on any medication that might increase chances of seizures?
  type:
    v: boolean
  required:
    v: true

link id:
  v: experience-background
text:
  v: Experience and Background
type:
  v: group
item:
  link id:
    v: vr-experience
  text:
    v: Have you ever experienced virtual reality?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: military-background
  text:
    v: Do you have a military background?
  type:
    v: boolean
  required:
    v: true
item:
  link id:
    v: education
  text:
    v: What is your highest level of education in a STEM related field?
  type:
    v: choice
  required:
    v: true
  answer option:
    value: String
      v: Bachelor
  answer option:
    value: String
      v: Master of Science
  answer option:
    value: String
      v: PhD
  answer option:
    value: String
      v: Medical Doctor
  answer option:
    value: String
      v: Other
item:
  link id:
    v: employment
  text:
    v: Employment Status
  type:
    v: choice
  required:
    v: true
  answer option:
    value: String
      v: US Civil Servant
  answer option:
    value: String
      v: Government Contractor
  answer option:
    value: String
      v: Military
  answer option:
    value: String
      v: Other
  answer option:
    value: String
      v: Unemployed
item:
  link id:
    v: referral-source
  text:
    v: How did you hear about HERA?
  type:
    v: choice
  required:
    v: true
  answer option:
    value: String
      v: Professional Organization
  answer option:
    value: String
      v: Recruitment Announcement
  answer option:
    value: String
      v: Conference
  answer option:
    value: String
      v: Social Media
  answer option:
    value: String
      v: Referred by Friend or Colleague
  answer option:
    value: String
      v: Online Search
  answer option:
    value: String
      v: Other

link id:
  v: additional-info
text:
  v: Please provide any additional information you wish us to consider in your application
type:
  v: text
max length:
  v: 500

link id:
  v: submission-consent
text:
  v: Submitting voluntary information constitutes your consent to the use of the information for the stated purpose. By submitting this form, you are providing voluntary consent to use the information submitted for the purpose stated. The final determination for clearance is the responsibility of NASA. You may be provided the opportunity to personally explain, refute, or clarify any information before a final decision is made.
type:
  v: display

link id:
  v: process-info
text:
  v: Typically, all applicants will be contacted within 5 to 7 business days following the submission of this application regarding its status. Eligible applicants may then be asked to provide additional screening information such as a professional resume or CV and must pass a federal background check.
type:
  v: display