SELF DECLARATION FORM

Disclosure of exposure or illness is required in order to safeguard the health and safety and restrict the outbreak in
the Sinarmas Agribusiness and Food community. Information collected will be kept safely and any personal
information will not be disclosed unless required by law or with the employee’s consent.

I, the undersigned below:

Employee ID : _____20001310__________________________________________
Candidate’s Name : ____RISWAN___________________________________________
Position title : ___DOKTER POLIKLINIK____________________________________________

Hereby declare that Ihave travelled out of town for business/personal purpose to below countries/cities:

Description 1 2 3
Country/City BANDA ACEH JAKARTA
Area of visit PANGKAL PINANG
Departure Date 15 NOVEMBER 2020
Returning Date -

Details of people, whom, you are living with:

Name Relationship Address Contact No

-
-
-
-
-

Check the list below, whether you:

① Have been in contact with patient of COVID-19

② Have been in contact with suspected carrier of COVID- 19

③ Have recently recovered from or been treated for COVID-19

④ Experienced the symptoms of COVID-19*

 ⑤ None of the list above

*Common symptoms of COVID-19 include fever, tiredness, dry cough and others symptoms include shortness of breath, aches and pains, sore
throat, diarrhoea, nausea or runny nose (WHO, 2020)

I understand the purpose of this declaration and the information provided is true at the point of submission.

Declared by, Received by, Acknowledged by,

Name: dr. Riswan Name: Name: Name:

Date: 2 Desember 2020 Date : Date: Date:
Employee Head of TA HRBP Lead Hiring Manager
 ISOLATION/QUARANTINE ORDER

(Recruiter choose either):

If you have ticked‘YES’ to item number 1 to 4 of the above-mentioned lists:

1. You must report yourself to HR and contact Hotline 119, from the date of contact with a
person diagnosed with, or suspected of being infected by, COVID-19 or the date you first
experienced symptoms. (Internal memo no. 006/AN-CHRO/SMART/03/2020)

2. Clearance from respected medical doctors prior to your joining day.

3. ?

OR

If you have travelled to the country that has affected by COVID-19:

1. You must self-isolate for a period of 14 days from the date you returned (Internal memo no.
006/AN-CHRO/SMART/03/2020)

2. You are ordered to be isolated at home……………………………..(address of isolation), from

dd//mm/yyyyuntil dd//mm/yyyy.(isolation/quarantine period with expiry timing), in
accordance with the order.

During the isolation/quarantine period, you must not leave the place of isolation/your home
(whichever is applicable) at any time.

You must remain contactable.

Your joining date will be changed to ……

Received by, Approved by,

Name: Name: Name: Name: Name:

Date : Date: Date: Date: Date:
Employee Head of Talent HRBP Lead Hiring Manager Division Head
Acquisition