SUBMIT FORM

The traveller hereby certifies that the information he/she has provided is true and that he/she subjects himself/herself to further assessment at a designated health facility (if he/she has any of the signs and symptoms listed above) OR subjects himself/herself to be monitored, either telephonically or physically at the place of destination in South Africa (if he/she does not have any of the signs and symptoms listed above), for development of Ebola symptoms (for a maximum of 21 days); and that he/she will notify health authorities if he/she develops any symptom of Ebola in the 21-day period following his/her suspected Ebola exposure date.

Signature of traveller: Date:

All sections are compulsory and should be completed

The following information must also be provided when requesting permission to travel:

South African telephone/cell phone number and South African residential address (if South Africa is the final destination) Details of next of kin (if South Africa is the final destination) Full motivation for the visit to South Africa

FOR OFFICE USE ONLY Port Health Official details Name:Tel:

Signature:

Health facility details if traveller referred Name of Health Facility Examining clinicianGENERAL COMMENTS:Province: Cell:

Port of entry:E-mail

Tel no. of facility

For further information please contact the National Health Operations Centre on 012 395 9636/9637 or email nathoc1@health.gov.za