Page 24 - DIDC SOPS and Guidelinesv as of April 2019

Antimalarial Questionnaire PMO-6018-01-c

Contingency Released Date
Operations 03/06/17 Page 1 of 1

NAME:_____________________________________

DEPLOYMENT DESTINATION:_________________________

DURATION OF DEPLOYMENT: ________________________

OCCUPATION: _____________________________

ARE YOU ALLERGIC TO DOXYCYCLINE OR TETRACYCLINE? Yes No Unknown

If yes, briefly describe the symptoms of your allergic reaction(s)?

IF YES, ALTERNATE ANTIMALARIAL TO BE PRESCRIBED:

I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE:

Signature Date

This document contains confidential and proprietary information of DynCorp International (“DI”).
No part of it may be used, circulated, quoted, or reproduced for distribution outside of DI without the prior written approval of DI.