EMPLOYEE DECLARATION OF COVID-19 COMORBIDITIES
Comorbidity is an underlying medical condition. Certain underlying medical conditions and illnesses have been identified to place the sufferer thereof at a higher risk for COVID-19, the Coronavirus infection.

The regulations in the Occupational Health and Safety Act, as well as the Disaster Management directives, expect of employers to identify employees with a high-risk profile and to take specific measures under these circumstances.

COVID-19 Comorbidities:
 People with chronic lung disease or moderate to severe asthma
 People who have serious heart conditions (including coronary artery disease)
 People who are 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
 Hypertension (high blood pressure)
 People with diabetes
 People with chronic kidney disease undergoing dialysis
 People with liver disease
 People with severe obesity (body mass index [BMI] ≥40]

PLEASE NOTE THAT THIS FORM NEEDS TO BE ACCOMPANIED BY A DOCTORS OR MEDICAL PRACTITIONERS LETTER. This letter can found in the link below and can be sent to the doctor directly. For a manual version of this form please ask your line manager.
Doctors Letter: https://docs.google.com/forms/d/e/1FAIpQLSdAxPBSOaIRvFuJQFCn8xipwaFNvZ5sk_oL7lUGyd3W5cxLqg/viewform)
Name of Line Manager? *
Name and Surname *
I hereby declare that I suffer from one or more of the comorbidities as listed above. *
Nature of comorbidity (Not Compulsory)
I understand that if I falsely claim to have one or more of these comorbidities that I am being dishonest and that my employer may invoke the disciplinary procedure to deal with such serious misconduct which could result in my dismissal. I understand that I may go to a medical practitioner who can declare me fit for work although I have COVID-19 comorbidity in his/her professional, medical opinion declare that it is under control (the link to the doctor's letter can be found alongside the link to this form on the Cornerstone website). This declaration has been explained to me in a way that I understand fully. *
SIGNED BY EMPLOYEE (Write Name):
SIGNED BY EMPLOYER (Write Name):
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