Are you required, either routinely or on the odd occasion, to be gloved and gowned whilst working in the sterile area?

YES

Do you work or may work in the presence of the patient?

YES

Do you have access or may have access whether directly or indirectly to patient personal information?

YES

Do you engage or may engage in one or more of these activities: market access activities, medical aid motivations, patient assistance programs, servicing and maintenance of equipment/systems that stores/processes patient personal information.

YES

Do you, for any reason, enter the hospital environment beyond the hospital foyer, medical practitioner rooms, pharmacy, lab and radiology?

YES

Do you enter the theatre environment even in the absence of a patient to count stock or to service/repair equipment?

YES

Are you representing a company that produces and/or promotes and/or sells foodstuffs used to feed infants and young children?

YES

LEVEL OF ACCESS REQUIRED:

Submit

20. For the ‘Company Declaration’, how do I go about completing this form?

The Company Declaration form is completed by the company and NOT you. This form does not apply to CRICE General – White card holders

Your company has appointed and authorised person to sign on its behalf.
Complete this persons’ name and email address and click on ‘Save and Send email’.
The authorised person will receive a link from noreply@masoom.co.za and can access to complete directly from the email link.
If you do not know who the authorised person is, then ask your CRICE Point of Contact who is in cc on this email.

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DETERMINE THE LEVEL OF ACCESS REQUIRED

LEVEL OF ACCESS REQUIRED: