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)
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 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:
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.
SIGNED (Write Name):
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