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: .....................................................................................................................................

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
1	Temperature if above 38 °C	°C/	°F
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: ________________________________

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)