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Africom.mil/staff-resources/travel-toafrica/general 20health 20counseling 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. HEALTH PRECAUTIONS FOR EACH COUNTRY IES TO BE VISITED AT 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 Checklist is used to guide screener with AFRICOM requirements - MEDICALLY READY IAW SERVICE OR AGENCY GUIDELINES CONTRACTORS IAW DODI 3020. 41 - NO ANSWER S MUST BE COMPLETED OR EXEMPTED OR WAIVED WAIVERS ONLY VIA THE AFRICOM COMMAND SURGEON - FOR WAIVER REQUIREMENT INFORMATION CONTACT africom.stuttgart. acsg. mbx. j004-force-health-protection mail.mil MEDICAL REQUIREMENTS VACCINATIONS CURRENT YES through August 2017 New influenza season - - HEPATITIS A 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 IS REQUIRED - - SEASONAL INFLUENZA CURRENT ANNUAL VACCINE - - VARICELLA DOCUMENTED IMMUNITY OR VACCINATION - - TYPHOID INJECTABLE EVERY 2 YRS ORAL EVERY 5YS - - MENINGOCOCCAL EVERY 5 YRS - - YELLOW FEVER EVERY 10 YRS LAST DOSE MUST BE AT LEAST 10 DAYS PRIOR TO ARRIVAL TO AFRICA - - RABIES / PNEUMOCOCCAL IF HIGH RISK AND AS NEEDED FOR OCCUPATIONAL EXPOSURE DOES NOT POSSESS A DUTY/DEPLOYMENT LIMITING MEDICAL CONDITION MEDGUIDE can be found at CURRENT PHA / Physical Military / Civilian LAB WORK CURRENT IAW SERVICE GUIDELINES -- HIV G6PD TB DNA DENTAL CLASS 1/2 STATUS MILITARY ONLY / Current dental screening IAW ACI 4200. Intelink. gov/ncmi/index. php Note No Chloroquine FEMALE ONLY PREGNANCY TESTED WITHIN 15 DAYS OF TRAVEL NEGATIVE FOR TRAVEL OF 30 DAYS OR MORE THE TRAVELER MEETS MEDICAL SCREENING REQUIREMENTS FOR ENTRY INTO THE AFRICOM AOR. O-6 or equivalent/Supervisor SIGNATURE AC FORM 42 23 May 2016 YES NO IF NO DATE COMPLETED EXEMPTED WAIVED. 41 - NO ANSWER S MUST BE COMPLETED OR EXEMPTED OR WAIVED WAIVERS ONLY VIA THE AFRICOM COMMAND SURGEON - FOR WAIVER REQUIREMENT INFORMATION CONTACT africom.stuttgart. acsg. mbx. j004-force-health-protection mail.mil MEDICAL REQUIREMENTS VACCINATIONS CURRENT YES through August 2017 New influenza season - - HEPATITIS A 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 IS REQUIRED - - SEASONAL INFLUENZA CURRENT ANNUAL VACCINE - - VARICELLA DOCUMENTED IMMUNITY OR VACCINATION - - TYPHOID INJECTABLE EVERY 2 YRS ORAL EVERY 5YS - - MENINGOCOCCAL EVERY 5 YRS - - YELLOW FEVER EVERY 10 YRS LAST DOSE MUST BE AT LEAST 10 DAYS PRIOR TO ARRIVAL TO AFRICA - - RABIES / PNEUMOCOCCAL IF HIGH RISK AND AS NEEDED FOR OCCUPATIONAL EXPOSURE DOES NOT POSSESS A DUTY/DEPLOYMENT LIMITING MEDICAL CONDITION MEDGUIDE can be found at CURRENT PHA / Physical Military / Civilian LAB WORK CURRENT IAW SERVICE GUIDELINES -- HIV G6PD TB DNA DENTAL CLASS 1/2 STATUS MILITARY ONLY / Current dental screening IAW ACI 4200. 09 Civilian personnel TRAVELER PRESCRIBED/ISSUED RECOMMENDED MEDICAL EQUIPMENT CAC-ENABLED WEBSITE https //www. ANIMALS IN THE AFRICOM AOR. 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 HTTP //PHC. AMEDD. ARMY. MIL/PHC 20RESOURCE 20LIBRARY/DEPLOYMEN TFOODRISKBRIEFING.PDF I HAVE SUFFICIENT CLOTHING/UNIFORMS TREATED WITH PERMETHRIN INSECT REPELLENT FOR THE DURATION OF TRAVEL. http //www. africom.mil/staff-resources/travel-toafrica/general 20health 20counseling 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. HEALTH PRECAUTIONS FOR EACH COUNTRY IES TO BE VISITED AT 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 Checklist is used to guide screener with AFRICOM requirements - MEDICALLY READY IAW SERVICE OR AGENCY GUIDELINES CONTRACTORS IAW DODI 3020. 41 - NO ANSWER S MUST BE COMPLETED OR EXEMPTED OR WAIVED WAIVERS ONLY VIA THE AFRICOM COMMAND SURGEON - FOR WAIVER REQUIREMENT INFORMATION CONTACT africom.stuttgart. AFRICOM AOR TRAVEL MEDICAL SCREENING CHECKLIST THIS MEDICAL SCREENING IS VALID FOR 30 DAYS FROM DATE ANNOTATED IN PART II TRAVELER WILL RETAIN AND PROVIDE THIS COMPLETED FORM WHENEVER SEEKING TRAVEL CLEARANCE TO THE AFRICOM AOR PART I TRAVELER S DATA PERSONAL HEALTH TRAVEL REQUIREMENTS COMPLETED BY TRAVELER NAME LAST FIRST MI GRADE DIVISION / DUTY PHONE TRAVEL DESTINATION S PRIOR TO ENTRY INTO THE AFRICOM AOR TRAVELER READ INITIAL EACH BOX I HAVE NOTIFIED MY PROVIDER OF MY TRAVEL DESTINATION S AND I HAVE OBTAINED SUFFICIENT QUANTITIES OF PRESCRIBED ANTI-MALARIAL MEDICATION No Chloroquine AND I WILL TAKE AS DIRECTED. I UNDERSTAND I MUST PROVIDE THIS COMPLETED FORM AS DIRECTED TO SUPPORT THEATER CLEARANCE TO THE AFRICOM AOR. I AM TRAVELING WITH A CDC FORM 731 YELLOW SHOT CARD STAMPED WITH AN OFFICIAL YELLOW FEVER CERTIFICATE WITHIN LAST 10 YEARS. I HAVE OBTAINED INSECT REPELLENT CONTAINING DEET AND WILL USE TO PREVENT INSECT BITES. AS NEEDED TO PREVENT INSECT BITES. 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.