Disaster Management Act, 2002 (Act No. 57 of 2002)

Notices

Purchase

FORM AC1

NOTIFICATION OF TRANSPORTATION OF A PATIENT/SICK PASSENGER PER AIRCRAFT/VESSELS/VEHICLE TO SOUTH AFRICA (AC1)

To be completed faxed or sent by e-mail (or phoned through) to the Port Health Officer at:
Port of Entry: ..............................................	Tel: .............................................................
E-mail: .......................................................	Fax: ............................................................
Province: ....................................................

MODE OF TRANSPORT INFORMATION

Mode of Transportation: _____________________________________________________
Flight/Vessel/registration no: _________________________________________________
Port of Entry/departure: _____________________________________________________
Date of departure: ______________________	Time of departure: _____________________
Point of Entry of disembarkation: ______________________________________________
Date of arrival: _________________________	Time of arrival: ________________________
Seat no: __________________________________________________________________

INFORMATION OF PATIENT/SICK PASSENGER

Name of patient/sick passenger: _____________________________________________________
Age: __________________________________	Gender: _____________________________
Nationality: _________________________________________________________________________
Medical condition of patient/Diagnosis (confirmed or suspected): ______________________________
Presenting Condition: _________________________________________________________________
Date of onset: _______________________________________________________________________
Treatment given thus far: ______________________________________________________________
Has the patient had fever during this illness or few days earlier (yes or no): _______________________
Countries lived in or visited during previous 21 days: _________________________________________
___________________________________________________________________________________

INFORMATION OF HOSPITAL/INSTITUTION IN SOUTH AFRICA

Name of hospital/institution responsible for treatment of patient: _____________________________
Treating doctor: _____________________________________________________________________
Contact person: _____________________________________________________________________
Tel: ___________________________________	Fax no: _____________________________
Email: _________________________________

MEDICAL EVACUATION COMPANY

Medical Evacuation Company: _________________________________________________________
Contact Person: _____________________________________________________________________
Tel: ___________________________________	Email: ______________________________
Airline/vessel/vehicle company responsible: _______________________________________________
Signature of Applicant: _____________________	Date: _______________________________