BHI Declaration Form

Malaria Control Program

Malaria-related health issues
(to be completed before receiving the Malaria Survival kit)

MALARIA SURVIVAL KIT

This kit is provided for the emergency treatment of acute uncomplicated Plasmodium Falciparum Malaria,
the malignant cerebral malaria commonly found in Africa / Asia Pacific / Latin America and other malaria
areas. This form of malaria can kill in 24–36 hours from first symptoms. Uncomplicated means early
symptoms of malaria such as fever, headache, and general malaise. This kit is provided for emergency
use in situations where medical help and effective drugs are not immediately available. However, it is
always better to seek appropriate medical attention. The medication provided in the kit is typically
Coartem. Alternative medication may be provided depending on the consent of the governing authorities
in the malaria-prone area.
There are a number of contraindications that must be considered before using this kit. If any of these
apply, do not use this kit:
• Complicated malaria (anything other than early symptoms)
• Pregnancy or lactation
• Other types of malarial infection such as recurrence of benign malaria
• Any family history of sudden death
• Any strong family or personal history of heart disease (also any known ECG abnormalities)
Should you choose to take the medication, you should also seek medical assistance IMMEDIATELY.
There are a number of special precautions where you must seek medical advice before taking the
medication. These include, but are not limited to:
• Any liver or kidney impairment
• Any abnormalities of the heart rhythm such that the pulse is not entirely regular
There are also some drug interactions, which should rule out the use of the kit. These include:
• Cispride • Anti-depressants
• Some antibiotics • Anti-fungals
• Any drug to stabilize the rhythm of the • Other anti-malarials (a malarial
heart breakthrough is considered complicated)
As with most medications, there may be some side effects with the medication. These are uncommon,
but may include:
• Headache • Dizziness
• Sleep disturbance • Palpitation
• Nausea or indigestion • Itching
• Rash • Joint or muscle pains
• Fatigue • Cough
I confirm that I have read and understood the above statements and this kit has been provided for my
sole use for the emergency treatment of acute uncomplicated P. Falciparum Malaria when professional
medical assistance and treatment are not quickly available. The kit is for my exclusive use and will not be
given to another individual. I also confirm that I will not use the kit in situations where contraindications
apply.

Employee Name : Employee Signature:

BHI Operation /
Current Malaria Work
Product and
Location (Country, City):
Technology:
Survival Kit #: Survival Kit Delivery Date:
O / P&T-MCO
Date:
Signature:
NOTE: Retain a signed original of this form in the employee’s personnel record.