Annex 1 Pre-travel Personal Data The following data should be kept confidential and only be used in case of emergency Personal Information Name__________________________________________________________________ Date of Birth ______________________________________________________________ Address_________________________________________________________________ E-mail address____________________________________________________________ Passport Details (Nr., Issue date, Expiry date, Place of issue) _________________________ _______________________________________________________________________ Nationality _____________________________________________________________ Insurance Company and Policy Number_________________________________________ Telephone_______________________ Mobile phone number________________________ Contact details in case of emergency (Next of kin*)__________________________________ Health Information Blood group______________________________________________________________ Vaccinations for travel if needed_______________________________________________ Malaria prevention if needed_________________________________________________ General Health Status _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Any other relevant health information (known allergies/medication etc) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Health / Travel Insurance Details Company________________________________________________________________ Contact_________________________________________________________________ Policy number____________________________________________________________ * Next of kin is a person most closely related to a given person 31