Daily Symptom Report
To be completed should an employee be presenting a symptom recorded on the Daily Health Screening document. Each employee presenting symptom/s must be reported.
Business ID
As issued by NIOH
Unit / Site Name
*
Unit / Site Code
*
Consent to Share Data
*
Please Select
Yes
No
Select either YES or NO
Employee ID
*
SA National ID or similar
Date of Symptom Screen
*
-
Year
-
Month
Day
The date of the symptom being recorded on the Daily Employee Health Screening document
Employee Age
*
Enter the age of the employee in years
Employee Gender
*
Please Select
Male
Female
Other
Enter the gender of the employee
Employee Job Category
*
Please Select
Managers
Professionals
Technicians and Associate Professionals
Clerical Support Workers
Services and Sales Workers
Skilled Agricultural, Forestry, Fishery, Craft and Related Trades Workers
Plant and Machine Operators and Assemblers
Elementary Occupations
Enter the category that best describes the employee's job description
Province
*
Please Select
Eastern Cape
Free State
Gauteng
KwaZulu-Natal
Limpopo
Mpumalanga
North West
Northern Cape
Western Cape
Enter the province of the employee's workplace
District /Metro
*
Please Select
Alfred Nzo
Amajuba
Amathole
Bojanala
Buffalo City
Cape Winelands
Capricon
Central Karoo
Chris Hani
City of Cape Town
City of Johannesburg
City of Tshwane
Dr Kenneth Kaunda
Dr Ruth Segomotsi Mompati
Ehlazeni
Ekurhuleni
eThekwini
Fezile Dabi
Frances Baard
Garden Route
Gert Sibande
Harry Gwala
iLembe
Joe Gqabi
John Taolo Gaetsewe
King Centshwayo
Lejweleputswa
Mangaung
Mopani
Namakwa
Nelson Mandela Bay
Ngaka Modiri Molema
Nkangala
OR Tambo
Overberg
Pixley ka Seme
Sarah Baartman
Sedibeng
Sekhukhune
Thabo Mofutsanyane
Ugu
Umgungundlovu
Umkhanyakude
Umzinyathi
Uthukela
Vhembe
Waterberg
West Coast
West rand
Xhariep
ZF Mgcawu
Zululand
Enter the nearest / most appropriate district or metro of the employee's workplace
Symptoms
*
Please Select
Yes
Symptoms disclosed by employee:
Fever
Please Select
Yes
No
Chills
Please Select
Yes
No
Dry Cough
Please Select
Yes
No
Sore Throat
Please Select
Yes
No
Shortness of Breath
Please Select
Yes
No
Tiredness
Please Select
Yes
No
Lack of Smell or Taste
Please Select
Yes
No
Conjunctivitis (Red Eyes)
Please Select
Yes
No
Diarrhoea
Please Select
Yes
No
Muscle Pains
Please Select
Yes
No
Nausea or Vomiting
Please Select
Yes
No
Dizziness
Please Select
Yes
No
Headache
Please Select
Yes
No
Screening Outcome
*
Please Select
No action required
Referred for self-isolation
Referred for testing
Referred to the doctor
Enter the outcome or actions taken based on the symptoms screening
Do you want to add another employee?
*
Please Select
Yes
No
Submit
Should be Empty: