Attachment I.docx

Attachment I

DEPARTMENT OF VETERANS AFFAIRS

In Reply Refer To: 111-H

Pursuant to Federal Aviation Regulations, a customer who would like to use a portable oxygen concentrator unit on board an airline must obtain a written statement from his or her physician answering the questions listed below:

CUSTOMER INFORMATION

This document is to remain in your personal possession and must be presented to airline representatives upon request. This document will not expire but must be available for every flight. Any changes in oxygen requirements such as revised flow rate will require an updated statement.

You are responsible for ensuring that your unit is in good condition and free from damage or excessive wear and tear.

You are responsible for traveling with a sufficient supply of batteries to last the entire journey, per your oxygen requirements, including the duration of that flight, all ground time (before and after flight and during connections) and for unexpected delays. All batteries must be transported in carry-on (not checked) baggage and must be packed in a manner that protects them from damage or short circuits. Your portable oxygen concentrator, as well as the baggage containing the batteries, is exempt from the normal carry-on limitation of one piece plus a personal item.

TO BE COMPLETED BY PHYSICIAN:

Patients Name: _____________________________________ Date: _________________________

Does this user of the device have the physical and cognitive ability to see, hear, understand, and take appropriate action in response to the device’s aural and visual cautions and warnings?

Yes ____________ No _____________ If not, the customer must travel with someone who is capable of performing those functions.

Is oxygen use medically necessary for continuous use during taxi, take-off, landing, and during flight?

Yes ____________ No ____________

Is oxygen use medically necessary for non-continuous (as needed) use?

Yes ____________ No ____________

Pressurized aircraft cabin altitude equals 8,000 feet above sea level. Recognizing the possible changes in cabin pressure during flight, the patient’s required oxygen flow rate during flight is ____________ LPM.

Physician’s Name: _______________________________________________

Telephone: ______________________________________________________

Signature: ______________________________________________________ VA 1624 Clinical Respiratory Assessment – Vent (VISN 12) Rev 6/4/2020 image1.png