TRAVEL APPOINTMENT ASSESSMENT FORM
Surname:
Mr/Ms/Mrs/Miss/Dr/Prof
First Name :
Date
Dateofofrequest:
birth:
Home address:
Department/College/Organisation:
Contact Telephone no.
E-mail:
Are you a member of the University? YES  NO 
Are you: University Staff?
Are you a student?
M.Sc.
Please give your University Card No

M.Phil.
Please indicate whether payment for any
medications and advice received in the
Travel Clinic will be the responsibility of
your department or you as an individual.
(please tick appropriate box)

D.Phil. 
Other
Department/College
Name of authorising person to be invoiced
Organisation
Name of authorising person to be invoiced
Individual
Have you visited the Travel Clinic
previously?
YES / NO
Individual or Group travel? (If group, are
you the group leader?)
YES / NO
Destination/s (include all countries and main cities/towns/areas to be visited/ stop overs):
Date of departure:
Duration of trip:
Purpose of visit: include a brief description
of the type of accommodation and
activities to be performed. Please explain
the nature of any fieldwork
Have you ever had, or do you now have any long-standing or temporary health condition(s), which could
affect your fitness to travel?
Examples would be a history of DVT, Heart or Respiratory disease, Diabetes, Pregnancy, recent surgery or
injury
YES / NO
Please complete your vaccination history to date:
You may need to contact your GP surgery for this information:
MMR:
Hepatitis A
Typhoid
Yellow Fever
BCG
Hepatitis B
Rabies
Tetanus/Diphtheria
/Polio
Meningitis ACWY or B
TicoVac
Jap Encephalitis
Other
I certify that the travel arrangements for which I am requesting travel advice and vaccination has approval by my Head
of Department or my Departmental Central Administrator.
N.B. This travel relates solely to journey/s to be taken on official University of Oxford business.
Signed………………………………………………………… Date: …………………………………………...
Or
My employer has a contract with Oxford University Occupational Health Service to provide a business travel service to
employees travelling on company business.
Signed...........................…………………………………………Date: …………………………………………
Or
I am responsible for the total cost of my travel health consultation and subsequent treatment provided in respect of my
impending travel on University business.
Signed...........................…………………………………………Date: …………………………………………
The information collected on this form is processed in accordance with the principles of the Data Protection Act 1998.
All information you provide is held securely in confidence as part of your medical record by the Occupational Health
Service.
To be completed by OH only:
Is an appointment required: Yes /No
Vaccinations required (please tick):
Td/IPV
Physician/ Nurse clinic appointment
Hepatitis A
Typhoid
Hepatitis B
Influenza
Yellow Fever
Rabies
Meningitis: B
or ACWY
Jap
Encephalitis
Tico Vac
MMR
Varicella
Advice and/or Other Medication required (please tick):
Malaria
Traveller’s
Diarrhoea
Other (e.g. health
issues identified
from risk
assessment)
TB
OHA/OHP
Signature:
Bite prevention
BCG Scar Yes /No
Date: