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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 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.

 

To be completed and faxed/sent by e-mail (or phoned through) to the Port Health Officer at:

NAME: ..............................................

Port of Entry: ..............................................

Tel: .......................................................

Fax: ............................................................

E-mail: ....................................................

 

Province: .....................................................................................................................................

 

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.

 

Flight no:                Seat no:                Date:                

Name of patient/sick passenger:

CONDITION OF PATIENT/SICK PASSENGER (Tick in relevant box)

NO

SIGNS/SYMPTOMS

Does the patient have the following symptoms?

YES

NO

UNCERTAIN

1

Fever

°C/

°F

Temperature if above 38 °C

2

Severe headache


3

Abnormal sweating


4

Rapid breathing (Shortness of breath)


5

Excessive coughing


6

Severe vomiting


7

Diarrhoea


8

Bleeding


 

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: ________________________________