EMPLOYEE DECLARATION OF COVID-19 COMORBIDITIES - To be completed by Medical Practitioner
Dear Doctor/Medical Practitioner,

Your patient is one of our employees.

NOTE THAT THIS IS NOT A SCREENING FOR COVID-19

Your patient has declared that s/he has one or more of the following comorbidities:
 Has chronic lung disease or moderate to severe asthma
 Has serious heart conditions (including coronary artery disease)
 Is immune-compromised
o Many conditions can cause a person to be immune-compromised, including cancer treatment, smoking,
bone marrow or organ transplantation, fibromyalgia, TB, immune deficiencies, poorly controlled HIV or
AIDS, and prolonged use of corticosteroids and other immune weakening medications
 Has Hypertension (high blood pressure)
 Has diabetes
 Has chronic kidney disease undergoing dialysis
 Has a liver disease
 Is severely obesity (body mass index ≥40]

The actual medical condition does not have to be declared. Any employee on this list is required to obtain a medical certificate declaring him/her healthy to work. Please complete the document in the following manner:
Email *
Name of the Medical Practitioner
Address of Practise
Contact Number for Practise
Name and Surname of Patient
I declare that my patient can continue with his/her normal employment duties and that the age and/or comorbidity identified will not put him/her at a higher risk in the working environment within the context of the COVID-19 infection.
Clear selection
SIGNED (Write Name):
Due date
MM
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YYYY
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