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    This Form Must Be Signed by A Physician.: WWW - Cdc.gov/travel

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    jemal

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    This Form Must Be Signed by A Physician.: WWW - Cdc.gov/travel

    Uploaded by

    jemal
    19 views1 page

    Original Title

    GoodHealth(1)

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    Copyright:

    © All Rights Reserved
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    Download as pdf or txt
    19 views1 page

    This Form Must Be Signed by A Physician.: WWW - Cdc.gov/travel

    Uploaded by

    jemal

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    This form must be signed by a physician.

    Name of Global Impact Fellow Volunteer (“The Participant”):______________________

    Dates of Travel: ______________________

    Location of Travel (“Location”): ______________________

    I, the undersigned, a physician duly licensed for the practice of medicine, hereby certify that I have
    examined the Participant. In the exercise of my best professional judgment, I certify that he/she
    enjoys good health and has no existing medical or health condition, physical, mental, or otherwise.*
    I also certify that he/she is receiving no treatment of any kind that would prevent or impede his/her
    participation in the Unite For Sight program in the Location, including travel thereto and strenuous
    extra-curricular activities.

    I confirm that the Participant has received all necessary vaccinations and malaria prophylaxis for
    travel to the Location, in accordance with The Traveler’s Health Report from the National Center of
    Infectious Diseases of the Centers for Disease Control (CDC): http://www.cdc.gov and http://
    www.cdc.gov/travel) for the Location.

    I confirm that there are no medical or psychiatric contraindications to participation, and the
    Participant is cleared to travel and participate in the developing country. I have discussed health
    and food/water precautions with the Participant and have also emphasized that he/she must bring a
    sufficient amount of any prescribed medication to last for the duration of travels. I have also
    suggested other relevant health advice for participation in the Location.

    *If Participant has a pre-existing medical or health condition, please initial here _________ and
    submit a separate letter that confirms your approval for the Participant to travel to the Location with
    the condition, despite the possibility of lack of quality medical care.

    Physician Name:
    ________________________________________, MD
    This form must be completed and signed by a physician.
    Licensed in the state/country of:
    ______________________________________________
    Address:
    ______________________________________________

    ______________________________________________

    ______________________________________________

    Phone number:
    ______________________________________________

    Physician Signature:
    ______________________________________________
    Date:
    ______________________________________________
    Physician Stamp:

    Unite For Sight ● 234 Church Street 15th Floor ● New Haven, CT 06510 ●
    203.404.4900 [email protected] ● www.uniteforsight.org

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