ac-form-42-africom-travel-health-checklist-15-jan-2019.pdf

USAFRICOM TRAVEL MEDICAL SCREENING CHECKLIST

TRAVELER WILL RETAIN AND PROVIDE THIS COMPLETED FORM WHENEVER SEEKING TRAVEL CLEARANCE TO THE AFRICOM AOR.

SCREENING IS VALID FOR 120 DAYS FROM PROVIDER SIGNATURE DATE IN PART II*.

PART I: TRAVELER’S DATA & PERSONAL HEALTH TRAVEL REQUIREMENTS (COMPLETED BY TRAVELER)

NAME: LAST, FIRST, MI GRADE DIVISION / DUTY PHONE TRAVEL DESTINATION(S) & DATES:

PRIOR TO ENTRY INTO THE AFRICOM AOR (TRAVELER READ & INITIAL EACH BOX)

I WILL NOTIFY MY PROVIDER OF MY TRAVEL DESTINATION(S); I WILL

OBTAIN SUFFICIENT QUANTITIES OF PRESCRIBED ANTI-MALARIAL

MEDICATION; AND I WILL TAKE AS DIRECTED.

IF I BECOME ILL WITHIN A YEAR AFTER TRAVELING TO THE USAFRICOM AOR, I

UNDERSTAND I AM TO SEEK MEDICAL ATTENTION AND INFORM MEDICAL

PERSONNEL THAT I HAVE TRAVELED TO AFRICA.

I HAVE ON-HAND SUFFICIENT QUANTITIES OF MY OTHER CURRENTLY

PRESCRIBED MEDICATION(S) AND/OR MEDICAL EQUIPMENT.

I UNDERSTAND I MUST PROVIDE THIS COMPLETED FORM, AS DIRECTED, TO

SUPPORT THEATER CLEARANCE TO THE AFRICOM AOR.

I HAVE OBTAINED INSECT REPELLENT CONTAINING DEET, PICARIDIN,

OR IR3535 AND WILL USE TO PREVENT INSECT BITES.

I AM TRAVELING WITH A CDC FORM 731 (YELLOW SHOT CARD)

STAMPED WITH AN OFFICIAL YELLOW FEVER CERTIFICATE.

I HAVE OBTAINED A PRE-TREATED BEDNET AND WILL USE TO PREVENT

INSECT BITES.

I UNDERSTAND I AM NOT TO PHYSICALLY CONTACT, KEEP OR FEED ANY

ANIMALS IN THE AFRICOM AOR.

I UNDERSTAND I AM NOT TO SWIM IN BODIES OF FRESH WATER OR SEA

WATER UNLESS APPROVED BY APPROPRIATE AUTHORITIES, AND IF

EXPOSED TO FRESH WATER, I WILL DRY OFF IMMEDIATELY.

I HAVE REVIEWED THE FOOD SAFETY BRIEF AT: HTTPS://PHC.AMEDD.ARMY.MIL/

PHC%20RESOURCE%20LIBRARY/DEPLOYMENT_FOOD_RISK_BRIEFING.PDF

I HAVE SUFFICIENT CLOTHING/UNIFORMS TREATED WITH

PERMETHRIN (INSECT REPELLENT) FOR THE DURATION OF TRAVEL.

I HAVE REVIEWED THE GENERAL HEALTH COUNSELING BRIEFING AT:

HTTP://WWW.AFRICOM.MIL/MEDIA-ROOM/DOCUMENT/30179/GENERAL-HEALTH-

COUNSELING

CIVILIANS/CONTRACTORS (including retired military): I UNDERSTAND

THAT I MAY NOT BE SYSTEMATICALLY COVERED BY ANY FORM OF

MEDICAL EVACUATION PLAN. I UNDERSTAND MY OPTIONS FOR MEDICAL

EVACUATION OUT OF THE AFRICOM AOR.

I HAVE REVIEWED THE FOREIGN CLEARANCE GUIDE (FCG), SECTION

VII.E. HEALTH PRECAUTIONS FOR EACH COUNTRY TO BE VISITED:

HTTPS://WWW.FCG.PENTAGON.MIL

FEMALE ONLY: I HAVE DISCUSSED MY PREGNANCY STATUS WITH

THE MEDICAL SCREENER.

I ACKNOWLEDGE AND HAVE MET PERSONAL MEDICAL REQUIREMENTS FOR ENTRY INTO THE AFRICOM AOR.

TRAVELER’S SIGNATURE: DATE: _______________

PART II: MEDICAL SCREENING REQUIREMENTS (COMPLETED BY MEDICAL SCREENER)

- MEDICALLY READY IAW SERVICE OR AGENCY GUIDELINES (CONTRACTORS IAW DODI 3020.41)

- “NO” ANSWER(S) MUST BE COMPLETED OR EXEMPTED OR WAIVED (VACCINES NOT WAIVERABLE)

- FOR WAIVER REQUIREMENT INFORMATION, CONTACT: africom.stuttgart.acsg.mbx.j004-force-health-protection@mail.mil

YES NO

IF NO,

DATE COMPLETED

VACCINATIONS CURRENT:

- - HEPATITIS A (SERIES COMPLETE OR FIRST DOSE AT LEAST 14 DAYS PRIOR TO TRAVEL)

- - HEPATITIS B (SERIES COMPLETE OR FIRST DOSE AT LEAST 14 DAYS PRIOR TO TRAVEL)

- - TETANUS-DIPHTHERIA (EVERY 10 YRS; ONE TIME ADULT BOOSTER OF TDAP IF NOT PREVIOUSLY RECEIVED)

- - MEASLES, MUMPS, RUBELLA (Serologic immunity or TWO LIFETIME DOSES ARE REQUIRED if born after 1957)

- - POLIOVIRUS (SERIES COMPLETE PLUS SINGLE ADULT BOOSTER AND COUNTRY-SPECIFIC REQUIREMENTS)

- - SEASONAL INFLUENZA (CURRENT ANNUAL VACCINE)

- - VARICELLA (DOCUMENTED IMMUNITY OR VACCINATION)

- - TYPHOID (INJECTABLE EVERY 2 YRS; ORAL EVERY 5 YRS)

- - MENINGOCOCCAL (EVERY 5 YRS)

- - YELLOW FEVER (DOSE MUST BE AT LEAST 10 DAYS PRIOR TO ARRIVAL TO AFRICA; SEE ACI 4200.09A)

- - RABIES (AS NEEDED FOR OCCUPATIONAL EXPOSURE, OTHER EXPOSURE RISK, OR HRIG UNAVAILABLE) CURRENT PHA / Physical (Military / Civilian) LAB WORK CURRENT IAW SERVICE GUIDELINES

DENTAL CLASS 1/2 STATUS (MILITARY ONLY) / Current dental screening IAW ACI 4200.09A (Civilian)

TRAVELER PRESCRIBED/ISSUED RECOMMENDED MEDICAL EQUIPMENT

TRAVELER PRESCRIBED RECOMMENDED MEDICATIONS FOR COMMON TRAVELER ILLNESSES

TRAVELER PRESCRIBED MALARIA CHEMOPROPHYLAXIS PER NCMI OR TRAVAX ASSESSMENT OF TRANSMISSION RISK: HTTPS://WWW.NCMI.DETRICK.ARMY.MIL OR HTTPS://WWW.TRAVAX.COM (Note: No Chloroquine) FEMALE ONLY: PREGNANCY TEST NEGATIVE (WITHIN 30 DAYS OF TRAVEL) FOR TRAVEL OF 30 DAYS OR MORE

AC FORM 42, 15 January 2019

* Screening validity may be modified per local SOP for unique mission requirements.

THE TRAVELER MEETS MEDICAL SCREENING REQUIREMENTS FOR ENTRY INTO THE AFRICOM AOR PER ACI 4200.09A

Provider SIGNATURE: __________________________________ DATE: _________________

For use of this form, see U.S. Africa Command Instruction 4200.09A

HTTPS://WWW.AFRICOM.MIL/STAFF-RESOURCES/MEDICAL-WAIVER-PROCESS

DOES NOT POSSESS A DUTY/DEPLOYMENT-LIMITING MEDICAL CONDITION IAW ACI 4200.09A

IF NEEDED, USE AC FORM 43, MEDICAL WAIVER REQUEST:

UNCLASSIFIED

UNCLASSIFIED

http://phc.amedd.army.mil/PHC%20RESOURCE%20LIBRARY/DEPLOYMENT_FOOD_RISK_BRIEFING.PDF mailto:africom.stuttgart.acsg.mbx.j004-force-health-protection@mail.mil https://www.fcg.pentagon.mil/static/AFRICOM_ACI_4200.09.pdf http://www.africom.mil/media-room/document/30179/general-health-counseling

HTTP://WWW.AFRICOM.MIL/STAFF-RESOURCES/MEDICAL-WAIVER-PROCESS

HTTPS://WWW.NCMI.DETRICK.ARMY.MIL

https://www.travax.com https://www.africom.mil/staff-resources/medical-waiver-process