COVID-19 Self Declaration - APAC 12 May 2020

If you are experiencing any COVID-19 symptoms that are abnormal for you, or answer “yes”
to questions 4-8 above, please 'DO NOT REPORT TO THE OFFICE OR SITE '. Please complete
this form, notify your supervisor and respective healthcare provider.
Hi Amriyani, when you submit this form, the owner will be able to see your name and email address.
Required
1.Select your country of work today
Indonesia
2.Select your department
Engineering
3.Where are you working today?
Home
Office
Other
4.Have you tested positive for COVID-19 in the last 21 days?
Yes
No
5.Are you currently feeling any abnormal symptoms possibly related to COVID-
19, or have had any in the last 14 days)?
- Cough
- Sore throat
- Shortness of breath or difficulty breathing
- Chills
- Repeated shaking with chills
Bergetar berulang kali dengan menggigil
- Muscle pain
- Headache
- New loss of taste or smell - Fever, temperature > 100* F / 38* C
Yes
No
6.Have you been in close contact within 6 feet (2 meters) for ≥ 15 minutes with
someone having one or more of the above symptoms within the past 14 days or
come into contact with a confirmed positive COVID -19 case?
Yes
No
7.Have you been in close contact with anyone confirmed to be COVID-19 positive
more than 14 days ago?
Yes
No
8.Have you travelled through or from another country in the last 14 days?
Yes
No
Submit