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  • Health Declaration Form

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    hikmah
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    This document is a health declaration form for visitors arriving in Indonesia. It asks for the visitor's identity information like name and nationality. It then asks if the visitor is experiencing any flu-like symptoms such as fever, cough or sore throat. It also asks if the visitor has traveled to or through countries like China, Hong Kong, Japan or Singapore in the last 30 days or had direct contact with a confirmed COVID-19 case in the last 14 days. The visitor must sign and date the form to confirm the information provided is accurate to the best of their knowledge.

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    HSE Form

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    This document is a health declaration form for visitors arriving in Indonesia. It asks for the visitor's identity information like name and nationality. It then asks if the visitor is experiencing any flu-like symptoms such as fever, cough or sore throat. It also asks if the visitor has traveled to or through countries like China, Hong Kong, Japan or Singapore in the last 30 days or had direct contact with a confirmed COVID-19 case in the last 14 days. The visitor must sign and date the form to confirm the information provided is accurate to the best of their knowledge.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    104 views1 page

    Health Declaration Form

    Uploaded by

    hikmah
    This document is a health declaration form for visitors arriving in Indonesia. It asks for the visitor's identity information like name and nationality. It then asks if the visitor is experiencing any flu-like symptoms such as fever, cough or sore throat. It also asks if the visitor has traveled to or through countries like China, Hong Kong, Japan or Singapore in the last 30 days or had direct contact with a confirmed COVID-19 case in the last 14 days. The visitor must sign and date the form to confirm the information provided is accurate to the best of their knowledge.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Lampiran 1

    FORMULIR DEKLARASI KESEHATAN (TAMU)


    HEALTH DECLARATION FORM (VISITOR)

    Identitas / identity
    Nama / name :
    Kebangsaan / nationality :
    Tanggalkedatangan / Arrival date in Indonesia :
    Datangdarinegara /Last Country of Embarkation :

    1. Apakahandasedangmengalamikeluhan di bawahini / Do you have any of the following flu like


    symptoms?
    - Demam / Fever
    - Batuk / Cough
    - Sakittenggorokan / Sore Throat
    - Pilek / Runny Nose
    - Sesaknafas / breathlessness
    - Lainnya, mohonjelaskan / Others, please specify_____________________________

    2. Apakahandadalam 30 hariterakhirberkunjungke Negara di bawahini ?


    Have you travelled through any of the following areas in the last 30 days?
    - CHINA (termasuk Macao), Hong Kong, Jepang, Singapura,
    CHINA (including Macao), Hong Kong, Jepang, Singapura
    - Ataunegaralainnya / Other Countries : ____________________________________

    3. ApakahAndapernahkontaklangsungdenganpenderita COVID-19 dalam 14 hariterakhir?


    Did you come in direct contact with confirmed case of Covid-19 in the last 14 days?
    Yes No
    Pernyataaninidibuatdengansebenar-benarnya
    I hereby confirm that the above information is accurate to the best of my knowledge:

    Tandatangan / Visitor’s Signature: ________________ Tanggal / Date: ___________


    --------------------------------------------------------------------------------------------------------------------
    DiisiolehPetugas CAP: PengukuranSuhuBadan : …. oC; NamaPetugas: ……………………

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