Disaster Management Act, 2002 (Act No. 57 of 2002)NoticesDirections from the Department of Health to prevent and combat the spread of COVID-19FormsForm AC1 : Notification of Transportation of a Patient/Sick Passenger per Aircraft/Vessels/Vehicle to South Africa (AC1) |
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: |
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Port of Entry: .............................................. |
Tel: ............................................................. |
E-mail: ....................................................... |
Fax: ............................................................ |
Province: .................................................... |
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MODE OF TRANSPORT INFORMATION
Mode of Transportation: _____________________________________________________ |
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Flight/Vessel/registration no: _________________________________________________ |
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Port of Entry/departure: _____________________________________________________ |
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Date of departure: ______________________ |
Time of departure: _____________________ |
Point of Entry of disembarkation: ______________________________________________ |
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Date of arrival: _________________________ |
Time of arrival: ________________________ |
Seat no: __________________________________________________________________ |
INFORMATION OF PATIENT/SICK PASSENGER
Name of patient/sick passenger: _____________________________________________________ |
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Age: __________________________________ |
Gender: _____________________________ |
Nationality: _________________________________________________________________________ |
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Medical condition of patient/Diagnosis (confirmed or suspected): ______________________________ |
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Presenting Condition: _________________________________________________________________ |
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Date of onset: _______________________________________________________________________ |
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Treatment given thus far: ______________________________________________________________ |
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Has the patient had fever during this illness or few days earlier (yes or no): _______________________ |
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Countries lived in or visited during previous 21 days: _________________________________________ |
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___________________________________________________________________________________ |
INFORMATION OF HOSPITAL/INSTITUTION IN SOUTH AFRICA
Name of hospital/institution responsible for treatment of patient: _____________________________ |
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Treating doctor: _____________________________________________________________________ |
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Contact person: _____________________________________________________________________ |
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Tel: ___________________________________ |
Fax no: _____________________________ |
Email: _________________________________ |
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MEDICAL EVACUATION COMPANY
Medical Evacuation Company: _________________________________________________________ |
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Contact Person: _____________________________________________________________________ |
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Tel: ___________________________________ |
Email: ______________________________ |
Airline/vessel/vehicle company responsible: _______________________________________________ |
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Signature of Applicant: _____________________ |
Date: _______________________________ |