<status value="active"/> <subjectType value="Patient"/> <date value="2025-05-18"/> <publisher value="MITRE"/> <contact> <name value="MITRE"/> <telecom> <system value="url"/> <value value="https://www.mitre.org/"/> </telecom> </contact> <description value="Application for the Human Exploration Research Analog (HERA) mission at NASA Johnson Space Center"/> <purpose value="To determine eligibility for the Flight Analog Project, including initial screening and evaluation to become a ground study subject."/> <copyright value="This information collection meets the requirements of 44 U.S.C 3507. OMB control number 2700-0174, expires 04/30/2026."/> <item> <linkId value="intro"/> <text value="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 value="display"/> </item> <item> <linkId value="privacy-statement"/> <text value="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 value="display"/> </item> <item> <linkId value="consent"/> <text value="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 value="display"/> </item> <item> <linkId value="citizenship"/> <text value="Are you a United States citizen?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="confinement-consent"/> <text value="For HERA missions, are you willing to be confined and isolated for required periods of time?"/> <type value="boolean"/> <required value="true"/> <item> <linkId value="confinement-details"/> <text value="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 value="display"/> </item> </item> <item> <linkId value="demographic-info"/> <text value="Demographic Information"/> <type value="group"/> <required value="true"/> <item> <linkId value="firstName"/> <text value="First Name"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="middleName"/> <text value="Middle Name"/> <type value="string"/> </item> <item> <linkId value="lastName"/> <text value="Last Name"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="phoneNumber"/> <text value="Phone Number"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="emailAddress"/> <text value="Email Address"/> <type value="string"/> <required value="true"/> </item> <item> <linkId value="confirmEmailAddress"/> <text value="Confirm Email Address"/> <type value="string"/> <required value="true"/> </item> </item> <item> <linkId value="age-check"/> <text value="Are you currently between the ages of 28 and 55?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="birthdate"/> <text value="Birthdate"/> <type value="date"/> <required value="true"/> </item> <item> <linkId value="sex"/> <text value="Sex"/> <type value="choice"/> <required value="true"/> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender"/> <code value="male"/> <display value="Male"/> </valueCoding> </answerOption> <answerOption> <valueCoding> <system value="http://hl7.org/fhir/administrative-gender"/> <code value="female"/> <display value="Female"/> </valueCoding> </answerOption> </item> <item> <linkId value="height"/> <text value="Height (in inches). For HERA missions, height not to exceed 6' 2" (74 inches)"/> <type value="decimal"/> <required value="true"/> </item> <item> <linkId value="weight"/> <text value="Weight (in pounds)"/> <type value="decimal"/> <required value="true"/> </item> <item> <linkId value="born-outside-us"/> <text value="Were you born outside of the United States?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="other-citizenship"/> <text value="Do you hold citizenship in any country other than the United States?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="tobacco-nicotine"/> <text value="Do you use any tobacco or nicotine products (select all that apply)?"/> <type value="choice"/> <required value="true"/> <repeats value="true"/> <answerOption> <valueString value="None"/> </answerOption> <answerOption> <valueString value="Smoking"/> </answerOption> <answerOption> <valueString value="Vaping"/> </answerOption> <answerOption> <valueString value="Chewing"/> </answerOption> <answerOption> <valueString value="Skin Patches"/> </answerOption> <answerOption> <valueString value="Other"/> </answerOption> </item> <item> <linkId value="medical-section"/> <text value="Medical History"/> <type value="group"/> <required value="true"/> <item> <linkId value="metal-in-body"/> <text value="Do you have any metal in your body other than dental work?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="claustrophobia"/> <text value="Are you claustrophobic?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="allergies-gi-diet"/> <text value="Do you have any of the following?"/> <type value="choice"/> <repeats value="true"/> <answerOption> <valueString value="Allergies (including food)"/> </answerOption> <answerOption> <valueString value="GI Disorders"/> </answerOption> <answerOption> <valueString value="Dietary Limitations"/> </answerOption> </item> <item> <linkId value="cardiovascular"/> <text value="Any cardiovascular or circulatory system issues?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="neurological"/> <text value="Any neurological problems?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="musculoskeletal"/> <text value="Any musculoskeletal problems?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="medications"/> <text value="Are you taking any medications?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="sleep-disorders"/> <text value="Any sleep disorders such as sleep walking or use of sleep aids?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="psychiatric"/> <text value="Any psychiatric disorders or history of mental illness?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="motion-sickness"/> <text value="Any motion sickness (not a disqualifier)?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="adhd-treatment"/> <text value="Any pharmacological treatment for ADHD?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="kidney-stones"/> <text value="Any history of kidney stones?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="ulcers"/> <text value="Any history of ulcers?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="epilepsy"/> <text value="Any history of epilepsy or other disorders of the brain?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="blood-clots"/> <text value="Any history of blood clots?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="family-seizures"/> <text value="Any history of close relatives with seizures?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="bisphosphonate"/> <text value="Are you currently on Bis-Phosphonate (for example, Fosamax, Boniva, or Reclast)?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="seizure-meds"/> <text value="Are you currently on any medication that might increase chances of seizures?"/> <type value="boolean"/> <required value="true"/> </item> </item> <item> <linkId value="experience-background"/> <text value="Experience and Background"/> <type value="group"/> <item> <linkId value="vr-experience"/> <text value="Have you ever experienced virtual reality?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="military-background"/> <text value="Do you have a military background?"/> <type value="boolean"/> <required value="true"/> </item> <item> <linkId value="education"/> <text value="What is your highest level of education in a STEM related field?"/> <type value="choice"/> <required value="true"/> <answerOption> <valueString value="Bachelor"/> </answerOption> <answerOption> <valueString value="Master of Science"/> </answerOption> <answerOption> <valueString value="PhD"/> </answerOption> <answerOption> <valueString value="Medical Doctor"/> </answerOption> <answerOption> <valueString value="Other"/> </answerOption> </item> <item> <linkId value="employment"/> <text value="Employment Status"/> <type value="choice"/> <required value="true"/> <answerOption> <valueString value="US Civil Servant"/> </answerOption> <answerOption> <valueString value="Government Contractor"/> </answerOption> <answerOption> <valueString value="Military"/> </answerOption> <answerOption> <valueString value="Other"/> </answerOption> <answerOption> <valueString value="Unemployed"/> </answerOption> </item> <item> <linkId value="referral-source"/> <text value="How did you hear about HERA?"/> <type value="choice"/> <required value="true"/> <answerOption> <valueString value="Professional Organization"/> </answerOption> <answerOption> <valueString value="Recruitment Announcement"/> </answerOption> <answerOption> <valueString value="Conference"/> </answerOption> <answerOption> <valueString value="Social Media"/> </answerOption> <answerOption> <valueString value="Referred by Friend or Colleague"/> </answerOption> <answerOption> <valueString value="Online Search"/> </answerOption> <answerOption> <valueString value="Other"/> </answerOption> </item> </item> <item> <linkId value="additional-info"/> <text value="Please provide any additional information you wish us to consider in your application"/> <type value="text"/> <maxLength value="500"/> </item> <item> <linkId value="submission-consent"/> <text value="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 value="display"/> </item> <item> <linkId value="process-info"/> <text value="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 value="display"/> </item> </Questionnaire>

Generated Narrative: Questionnaire HERAAnalogMissionApplication

Structure

LinkID	Text	Cardinality	Type	Description & Constraints
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
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
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
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
citizenship	Are you a United States citizen?	1..1	boolean
confinement-consent	For HERA missions, are you willing to be confined and isolated for required periods of time?	1..1	boolean
confinement-details	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.	0..1	display
demographic-info	Demographic Information	1..1	group
firstName	First Name	1..1	string
middleName	Middle Name	0..1	string
lastName	Last Name	1..1	string
phoneNumber	Phone Number	1..1	string
emailAddress	Email Address	1..1	string
confirmEmailAddress	Confirm Email Address	1..1	string
age-check	Are you currently between the ages of 28 and 55?	1..1	boolean
birthdate	Birthdate	1..1	date
sex	Sex	1..1	choice	Options: 2 options
height	Height (in inches). For HERA missions, height not to exceed 6' 2" (74 inches)	1..1	decimal
weight	Weight (in pounds)	1..1	decimal
born-outside-us	Were you born outside of the United States?	1..1	boolean
other-citizenship	Do you hold citizenship in any country other than the United States?	1..1	boolean
tobacco-nicotine	Do you use any tobacco or nicotine products (select all that apply)?	1..*	choice	Options: 6 options
medical-section	Medical History	1..1	group
metal-in-body	Do you have any metal in your body other than dental work?	1..1	boolean
claustrophobia	Are you claustrophobic?	1..1	boolean
allergies-gi-diet	Do you have any of the following?	0..*	choice	Options: 3 options
cardiovascular	Any cardiovascular or circulatory system issues?	1..1	boolean
neurological	Any neurological problems?	1..1	boolean
musculoskeletal	Any musculoskeletal problems?	1..1	boolean
medications	Are you taking any medications?	1..1	boolean
sleep-disorders	Any sleep disorders such as sleep walking or use of sleep aids?	1..1	boolean
psychiatric	Any psychiatric disorders or history of mental illness?	1..1	boolean
motion-sickness	Any motion sickness (not a disqualifier)?	1..1	boolean
adhd-treatment	Any pharmacological treatment for ADHD?	1..1	boolean
kidney-stones	Any history of kidney stones?	1..1	boolean
ulcers	Any history of ulcers?	1..1	boolean
epilepsy	Any history of epilepsy or other disorders of the brain?	1..1	boolean
blood-clots	Any history of blood clots?	1..1	boolean
family-seizures	Any history of close relatives with seizures?	1..1	boolean
bisphosphonate	Are you currently on Bis-Phosphonate (for example, Fosamax, Boniva, or Reclast)?	1..1	boolean
seizure-meds	Are you currently on any medication that might increase chances of seizures?	1..1	boolean
experience-background	Experience and Background	0..1	group
vr-experience	Have you ever experienced virtual reality?	1..1	boolean
military-background	Do you have a military background?	1..1	boolean
education	What is your highest level of education in a STEM related field?	1..1	choice	Options: 5 options
employment	Employment Status	1..1	choice	Options: 5 options
referral-source	How did you hear about HERA?	1..1	choice	Options: 7 options
additional-info	Please provide any additional information you wish us to consider in your application	0..1	text	Max Length: 500
submission-consent	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.	0..1	display
process-info	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.	0..1	display
Documentation for this format