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

Notices

Directions from the Department of Health to prevent and combat the spread of COVID-19

Forms

Form 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:

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: _______________________________