National Small Business Act, 1996 (Act 102 of 1996)
R 385
Disaster Management Act, 2002 (Act No. 57 of 2002)NoticesDirections from the Department of Health to prevent and combat the spread of COVID-19FormsForm AC2 : Notification of Symptoms of Patient/Sick Passenger transported per Vessels/Vehicle/Aircraft to South Africa (AC2) |
FORM AC2
NOTIFICATION OF SYMPTOMS OF PATIENT/SICK PASSENGER TRANSPORTED PER VESSELS/VEHICLE/AIRCRAFT TO SOUTH AFRICA (AC2)
| 1. | To be completed by Medical companies |
The form should be faxed or sent by e-mail to the Port Health Officer (PHO) or may be submitted to the PHO on arrival.
The form should be given to pilot/captain/driver who should give the information to the PHO of the destination port;
Reference number of PHO on form PH1 to approve transportation;
A completed Form AC1 should accompany this form if not yet submitted to PHO.
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To be completed and faxed/sent by e-mail (or phoned through) to the Port Health Officer at: |
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NAME: .............................................. |
Port of Entry: .............................................. |
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Tel: ....................................................... |
Fax: ............................................................ |
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E-mail: .................................................... |
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Province: ..................................................................................................................................... |
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OR
To be completed by Pilot/Captain/driver (crew member on his/her behalf) with the sick passenger on board.
Information should be provided to Port Coordinators/immigration officers or the control tower of the destination airport; or the form should be submitted to the PHO on arrival.
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Flight no: Seat no: Date: |
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Name of patient/sick passenger: |
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CONDITION OF PATIENT/SICK PASSENGER (Tick in relevant box) |
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NO |
SIGNS/SYMPTOMS Does the patient have the following symptoms? |
YES |
NO |
UNCERTAIN |
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1 |
Fever |
°C/ |
°F |
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Temperature if above 38 °C |
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2 |
Severe headache |
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3 |
Abnormal sweating |
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4 |
Rapid breathing (Shortness of breath) |
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5 |
Excessive coughing |
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6 |
Severe vomiting |
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7 |
Diarrhoea |
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8 |
Bleeding |
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Other symptoms/Diagnosis (Confirmed or working): _____________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
NB Temperature to be written down, whether the patient has a fever or not (Compulsory)
I hereby confirm that the above -mentioned information is true and correct:
Name and Surname: ______________________________________________
Signature: _____________________________ Date: ________________________________
