Figure 4. Travel Requirements (from SMC Form)

Alternative Text
•	Pre-departure:
o	Treatment
o	Check
o	Pregnant, EDD dd-MMM-YYYY
o	Hospitalization
•	Escort Type:
o	Individual
o	Group
o	Doctor
o	Nurse Specialist: _ _ _ _
o	Non-medical
•	Wheelchair:
o	WCHR (Can Walk Up Stairs)
o	WCHS (Not Able to Walk Up Stairs)
o	WCHC (Carry-on)
•	In-flight:
o	Extra Seat
o	3 Seats
o	Stretcher
o	IV Rx
o	Airlift
o	Oxygen, at __ LPM to
o	FD*
o	POE*
•	Disability Code:
o	BLND (blind)
o	DEAF
o	MED (medical case)