Form 2120-XXXX International Traveler Information Card

Federal Aviation Administration

OMB CONTROL NUMBER: 2120-XXXX
EXPIRATION DATE: mm/dd/yyyy

International Traveler Information Card
ONLINE FORM
- SENSITIVE BUT UNCLASSIFIED // FOR OFFICIAL USE ONLY Paperwork Reduction Act Burden Statement
A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty
for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a currently valid OMB Control Number. The OMB Control Number for this information
collection is 2120-XXXX. Public reporting for this collection of information is estimated to be approximately 30 minutes per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information.
All responses to this collection of information are mandatory (22 U.S.C. 3927 and 4802). Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information
Collection Clearance Officer, Federal Aviation Administration, 10101 Hillwood Parkway, Fort Worth, TX 76177-1524.
INSTRUCTIONS. Please fill in the below information to the best of your ability. If you are deploying to Post and do not have your
information at the initial time of completion, be certain to enter "TBD" in appropriate fields and fill-in the information as you receive it when
you are at Post. Enter "N/A" for any fields that do not apply to you but are marked as required. All fields marked with a red asterisk (*)
require a response.
NOTICE. This information is used exclusively to help save your life in an isolating event abroad. The accuracy and timeliness of the
information that you provide may prove critical in assisting you or your family members in an isolating event abroad.

PERSONAL INFORMATION

LAST NAME *

FIRST NAME *

MIDDLE INITIAL

OTHER NAMES (Last Name, First Name, MI; Separate by ";")
DATE OF BIRTH *

GENDER * See Appendix A

AGENCY/SECTION/DEPARTMENT

PERSONAL E-MAIL

CELL PHONE NUMBER #1

IMEI NUMBER #1

PROFESSIONAL E-MAIL

CELL PHONE NUMBER #2

IMEI NUMBER #2

PHYSICAL DESCRIPTION
(Please use U.S. Customary Units, i.e. feet, inches, pounds)

HEIGHT (5'10") *

WEIGHT *

HAIR COLOR *

SHIRT SIZE

PANT SIZE

SHOE SIZE

RACE See Appendix A

BLOOD TYPE

SCARS / MARKS / TATTOOS (If none indicate by "N/A")

EYE COLOR *

RhD Antigen

MEDICAL CONDITIONS
CAUTION. Providing this medical information is optional and completely voluntary. The information is stored on the
Department of State SBU network with access limited to certain security personnel. It is not part of your medical
record and the risk of inadvertent release is very small but present. It may be disclosed to rescue and support
personnel and assist them if you are involved in an emergency incident.
Reference: 12 FAH-1 Annex G 9.1 (U) Instructions for Completing Exemplar
I have read the above statement of caution and understand that SECTION 4.0 is optional and completely voluntary.
KNOWN MEDICAL CONDITIONS (comma-separated value(s))

KNOWN MEDICAL PRESCRIPTIONS (comma-separated value(s))

ALLERGIES (comma-separated value(s))

CAPABILITY / TRAINING INFORMATION
SPECIALIZED BRIEFING/TRAINING

In the aforementioned field, describe any specialized briefings or trainings you have received such as Post Security Briefings, Hostage
Survival Training, DoD Survival, Evasion, Resistance and Escape training, etc.
LANGUAGE CAPABILITIES (reading, writing, speaking)

AUTHENTICATION INFORMATION
DURESS INDICATOR. Select an easily remembered word that an individual can use during a normal conversation as a covert signal to alert
other personnel of their duress. An example of a duress word would be: "Sunglasses." A person is being carjacked and sets off a 911 function
from their personal travel locator. RSO calls the person and asks if they are OK. The person in distress (possibly being held at gunpoint and is
being told not to say anything) could respond "I hit the panic button by accident trying to find my sunglasses."

DURESS WORD

AUTHENTICATION INFORMATION (Continued...)
PERSONAL AUTHENTICATOR STATEMENTS. Select two, simple, declarative statements, that can be used to authenticate your identity.
The statements should involve easily remembered personal events or details that are not subject to change. A minimum of four questions must
be derived from each statement.
An example of a declarative statement: "While living in San Jose, California in 1972, I had a brown and white Dalmatian dog named Pepper."
The following questions can be derived from this statement:
1.
2.
3.
4.

What colour was your dog?
What state did you live in 1972?
What city did you live in 1972?
What type of dog did you have in 1972?

PERSONAL AUTHENTICATOR STATEMENT #1 *

PERSONAL AUTHENTICATOR STATEMENT #1 *

NEXT OF KIN CONTACT INFORMATION
LAST NAME

FIRST NAME

ADDRESS (Address, City, State\Country, Zip Code)

PERSONAL E-MAIL ADDRESS

MIDDLE INITIAL

RELATIONSHIP
TELEPHONE NUMBER