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Needed Scuba Assistance Assessment Form to Be Completed by Diveheart Adaptive Scuba Instructor

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Needed Scuba Assistance Assessment Form to Be Completed by Diveheart Adaptive Scuba Instructor Needed Scuba Assistance Assessment Form To Be Completed By Diveheart Adaptive Scuba Instructor Note: Please review the Adaptive Diver Registry (ADR) Form with the Adaptive Diver and any needed guardian for completeness and accuracy prior to filling out this form. PROFILE INFORMATION Adaptive Diver Full Name: Adaptive Scuba Instructor Full Name: Date of Assessment: Initial Assessment Final Assessment UPDATE Additional Notes And Comments From Instructor: DIVEHEART PAPERWORK NEEDED FOR ADAPTIVE DIVER 1) RSTC Medical Form 2) Physician Clearance Date: 3) Diveheart Liability Form 4) Diveheart Safe Diving Practices 5) Adaptive Diver Registry (ADR) 6) Release for Minors YES N/A 7) Diveheart Non-Agency Disclosure 8) Diveheart Media Release YES Declined SCORING INSTRUCTIONS: Check only one of the numerical values that correspond to each of the particular needs and scuba skills itemized below. If the diver does not require any assistance for any of items below, check the first column. If the diver “may” require assistance with the scuba skill, check the middle column. If the diver “does” require assistance, check the third column. Add all of the values to arrive at a total NSA score. If there is any reasonable doubt as to whether a diver “may” or “does” require assistance in the future, err on the side of caution and choose the higher value. KEY SCUBA SKILLS No May Does 1 Full Face Mask 0 6 6 2 Controlled descents and ascents 0 3 6 3 Equalization (ear and mask) 0 3 6 4 Out of air emergencies 0 3 6 Last Updated: May 2020 1|3 ©Diveheart Foundation PRECAUTIONS AND SCUBA SKILLS No May Does 5 Monitoring of Autonomic Dysreflexia 0 .5 1 6 Transfers 0 .5 1 7 Thermal regulation protections 0 .5 1 8 Skin protection 0 .5 1 9 Pressure sore protection 0 .5 1 10 Surface and U/W swimming 0 .5 1 11 UW communications signs & audible signals 0 .5 1 12 Leg bag and catheter precaution 0 .5 1 13 Diving system assembly and disassembly (at water’s edge) 0 .5 1 14 Donning and removing scuba equipment/apparel topside 0 .5 1 15 Equipment inspection (at water’s edge) 0 .5 1 16 Entries and exits 0 .5 1 17 Proper weighting 0 .5 1 18 Mouthpiece clearing—snorkel/regulator 0 .5 1 19 Regulator/snorkel exchanges at the surface 0 .5 1 20 Buoyancy control 0 .5 1 21 Mask-clearing 0 .5 1 22 Mask removal and replacement 0 .5 1 23 Buddy-system techniques 0 .5 1 24 Diver assistance techniques (self/buddy/group) 0 .5 1 25 Surface-snorkel swimming with full diving system 0 .5 1 26 Regulator recovery/retrieval 0 .5 1 27 Underwater removal and replacement of weight system 0 .5 1 28 Removal and replacement of scuba system 0 .5 1 29 Equipment care and maintenance (at the water’s edge) 0 .5 1 30 Underwater navigation 0 .5 1 Total NSA SCORE: ____________________ Last Updated: May 2020 2|3 ©Diveheart Foundation REQUIRED ADAPTIVE DIVE GEAR (Check all that apply) Descent line Full face mask with communications Full face mask Bail out traditional dive mask Redundant supply valve and pony tank 6 inch hoses with quick disconnect Transfer Harness Walker and/or cane Boat/Beach Wheelchair Belts/lashes for securing wheelchair/diver Ankle weights, clip-ons, weight harness Skin/wetsuit Swimming gloves Prosthetic fins Underwater propulsion device Prescriptive mask Pressure sore protection gear Thermal protection clothing/gear Regulator necklace Other: NOTES: ADAPTIVE DIVER’S CERTIFICATION LEVEL NSA SCORE: ________ 1. ADAPTIVE DIVE TEAM (ADT) NSA Score of 25 or less Requires at least two certified Adaptive Dive Buddies for all diving activities. 2. ADVANCED ADAPTIVE DIVE TEAM (A-ADT) NSA Score greater than 25, OR regardless of score, Adaptive Diver requires assistance with any of the following; controlled ascents/descents, equalization, out of air emergencies, and/or uses a full face mask Requires at least on Advanced Adaptive Dive Buddy and one Adaptive Dive Buddy for all diving activities. 3. Advanced Adaptive Dive Team Plus (AADT+) NSA Score greater than 25, OR regardless of score, Adaptive Diver requires assistance with any of the following; controlled ascents/descents, equalization, out of air emergencies, and/or uses a full face mask AND requires some other special assistance, adaptation, procedures, or equipment. Requires either an Adaptive Scuba Instructor or Advanced Adaptive Dive Buddy and one additional Adaptive Dive Buddy, and may require adaptive equipment or other particular assistance. I, ____________________________________________, (adaptive diver), have reviewed the above assessment and accept my certification level and the requirements I must follow. Print Adaptive Diver’s Name: Adaptive Diver’s Signature: Date: Adaptive Scuba Instructor’s Signature: Date: Last Updated: May 2020 3|3 ©Diveheart Foundation .
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