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    The document is a medical clearance form for international travel from NASA. It requires travelers to provide personal information like name, date of birth, and projected travel itinerary. The form also ensures travelers have received required immunizations for places they will visit based on CDC guidelines. It documents any medications, medical conditions, or allergies and whether the traveler has been evaluated by their personal medical doctor for the trip. The form is signed by the traveler and indicates if they are medically cleared for the international travel.

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    The document is a medical clearance form for international travel from NASA. It requires travelers to provide personal information like name, date of birth, and projected travel itinerary. The form also ensures travelers have received required immunizations for places they will visit based on CDC guidelines. It documents any medications, medical conditions, or allergies and whether the traveler has been evaluated by their personal medical doctor for the trip. The form is signed by the traveler and indicates if they are medically cleared for the international travel.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    9 views1 page

    Media Cal

    Uploaded by

    joonyman
    The document is a medical clearance form for international travel from NASA. It requires travelers to provide personal information like name, date of birth, and projected travel itinerary. The form also ensures travelers have received required immunizations for places they will visit based on CDC guidelines. It documents any medications, medical conditions, or allergies and whether the traveler has been evaluated by their personal medical doctor for the trip. The form is signed by the traveler and indicates if they are medically cleared for the international travel.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    National

    Aeronautics and Medical Clearance


    Space
    Administration for International Travel
    (REFERENCE: NPR 1810.1, "Health Services for International Travel or Assignment")
    NAME DATE OF BIRTH NASA ORGANIZATION/MAIL STOP CONTRACTOR CODE

    PROJECTED ITINERARY
    ANTICIPATED DATES COUNTRY CITY/REGION DURATION (INCLUSIVE DATES)
    DEPARTURE RETURN

    IMMUNIZATIONS (PER CDC)


    REQ REC LAST RECEIVED DATE OF BOOSTER

    YELLOW FEVER

    TETANUS/DIPHTHERIA (TD)

    MEASLES (OR MMR)

    POLIO
    ORAL INJECTION
    TYPHOID

    HEPATITIS A SERIES

    HEPATITIS B SERIES

    MENINGOCOCCUS

    VIRAL ENCEPHALITIS

    HUMAN IMMUNE GLOBULIN

    OTHER:
    ADM READ POS NEG
    TUBERCULOSIS SCREENING (PPD)
    MEDICATION DOSE REGIMEN/DURATION
    MALARIA PROPHYLAXIS

    MEDICATION DOSE REGIMEN/DURATION


    TRAVELER'S DIARRHEA

    TRAVELER'S HEALTH SUMMARY


    SIGNIFICANT PAST OR PRESENT MEDICAL CONDITIONS KNOWN ALLERGIES
    PERTAINING TO THIS TRAVEL

    CURRENT MEDICATIONS (Rx & OTC)

    EVALUATION BY TRAVELER'S PERSONAL MEDICAL YES NO IF YES, DOCTOR'S NAME:


    DOCTOR (PMD)?
    IS A WRITTEN COPY OF THE EVALUATION IN THE H.U. CHART? YES NO

    MEDICALLY CLEARED FOR THIS TRAVEL? YES NO

    TRAVELER'S NAME TRAVELER'S SIGNATURE DATE

    NASA FORM 1711 SEP 07 PREVIOUS EDITIONS ARE OBSOLETE.

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