Page 29 - DIDC SOPS and Guidelinesv as of April 2019

DIDC Pre-Deployment Worksheet PMO-6018-01-e

Contingency Released Date
Operations 03/06/17 Page 1 of 2

Date (MMMDDYYY): ______________

Name (Last, First MI): _____________________________ SSN: _________________________

Deploying to: ____________________ DOB (MM/DD/YYYY): _______________

Height: Weight:

HAVE YOU HAD A: SPLENECTOMY? YES NO

THYMECTOMY OR THYMUS DISEASE? YES NO

IMMUNIZATION (DATE OF LAST) SOURCE IMMUNIZATION (DATE OF LAST) SOURCE

ANTHRAX MMR Live Virus

TD PNEUMOCOCCAL Splenectomy

TDaP PPD TB SKIN TEST

HEPATITIS A SMALLPOX Live Virus

HEPATITIS B TYPHOID

HEP A-B TWINRIX YELLOW FEVER Live Virus

INFLUENZA POLIO

FLUMIST Live Virus VARICELLA Live Virus

MENINGOCOCCAL OTHER

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