University of Tasmania, Australia

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Before you prepare your plan you need to collect the following information.

• Name
  Date of Birth 12345678910111213141516171819202122232425262728293031JanFebMarAprMayJunJulAugSepOctNovDec1960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990
  Email address
• Date of last personal HIV antibody testing 12345678910111213141516171819202122232425262728293031JanFebMarAprMayJunJulAugSepOctNovDec198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012
  Hep B surface antibodies? NoYes
  Hep A vaccination? NoYes
• Country visiting Aland IslandsAlbaniaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei darussalamBulgariaCambodiaCameroonCanadaCape VerdeCayman IslandsChadChileChinaChristmas IslandsCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEl SalvadorEquatorial GuineaEstoniaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuinea BissauGuyanaHeard Island and Mc Donald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic republic of)IrelandIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic people's Republic ofKorea, Republic ofKuwaitLao people's democratic republicLatviaLebanonLesothoLiechtensteinLithuaniaLuxembourgMacauMacedonia, The Former Yugoslav Republic OfMalawiMalaysiaMaldivesMaliMaltaMarshall islandsMartiniqueMauritiusMayotteMexicoMicronesia (Federated States of)Moldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNiueNorfolk IslandsNorthern Mariana IslandsNorwayOmanPalauPalestinian Territory, OccupiedPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussia FederationRwandaSaint BarthelemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre et MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandTaiwan, Province of ChinaTajikistanTanzania, United Republic OfThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican City State (Holy See)VenezuelaVietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and Futuna IslandsWestern SaharaZambia
  Background HIV prevalence in that country
  Common associated comorbidities (e.g. TB)
• Does the visiting hospital have HIV PEP easily available? NoYes
  What drugs do they use?
• Current first line Highly active Anti-Retroviral Treatment (HAART) in hospital/country visited?
• Does the hospital have a post HIV exposure plan? NoYes
  Can you obtain a copy? NoYes
• Who is the local/regional specialist in HIV medicine?
  Contact number
• Where would you get serology performed for you (and the patient)?
• Supervisor name (host hospital)
  Contact number
• Name of the closest HIV specialist
  Contact number
  Institution
• Director of Electives (UTAS) contact number
• Airline for return home travel
  Contact number
• Travel insurer
  Contact number
• Next of kin contact number