DCCCD Form 5: Medical Emergency Information Completing this form is voluntary but strongly encouraged. The following information is voluntary on your part, but can help travel leaders and college staff in the case of an emergency. We encourage you to be as detailed as possible. This information is strictly confidential and will not be shared with any individual or organization not directly affiliated with the health and safety of project participants. Attach additional pages or information if necessary. If you do not wish to provide this information, go to the line titled “Decline to Answer,” sign and date. Note: This form contains sensitive, personal data and stored in digital, encrypted format on the DCCCD network supported platform (NOT Dropbox, c: drive, jump drive, etc.) This information will be available only to those with the proper clearance and in emergency only. 1. Please list any medical or mental health conditions you have in the event you require treatment during your travel abroad. 2. Please list any medications that you are currently taking or expect to be taking during the time of travel (include brand name and generic name if possible). Note: For prescription medications, ask your pharmacist for a copy of the prescription in case you need to have anything replaced during your trip. NOTE: Different countries may have legal restrictions on medications available in the US. Consult your physician if you have questions or concerns.