Form: TKI-TFCov-02 Rev2

PERIODICAL SURVEILLANCE FORM

TKI SELF ASSESSMENT of COVID-19 RISK
Penilaian Diri Terhadap Risiko COVID-19

Nama (Name) :
Nomor ID (ID Number) :
Departmen/Bagian (Departemen/Section) :
Tanggal (Assessment Date) :

Demi kesehatan dan keselamatan Bersama di tempat kerja, diharap untuk JUJUR dalam menjawab pertanyaan di bawah
ini.
For our health and safety in the workplace, HONEST is required in answering the questions below.

Dalam 7 hari terakhir, apakah Anda pernah mengalami hal-hal berikut :

In the past 7 days ago, have you experienced the following :

1. Apakah pernah ke tempat umum (pasar, fasilitas pelayanan kesehatan, kerumunan orang, dan lain-lain)?
Have you ever gone to public place (markets, health care facilities, crowds of people, etc.)?
Jika Ya (if Yes)
Pakai Masker Jarak
berapa lama
Tempat Umum Ya/Tidak berapa (wear mask) (distance)
(Public Place) (Yes/No) (paling lama)
sering Kadang dibuka
duration Selalu
(how often) (sometimes < 1Mtr > 1Mtr
(longest one) (always)
open)
Pasar
(Traditional market)
Mall
(Mall)
Mini market
(minimarket)
Sarana Olahraga
(Sports facilities)
Rumah Sakit
(Hospital)
Klinik
(Clinic)
Restoran
(Restaurant)
Tempat Ibadah
(worship place)
Dalam satu ruangan
dengan orang lain (misal
Karaoke, antrian bank,
dsb)
In one room with other
people (e.g. Karaoke, bank
queues, etc.)

2. Apakah memiliki riwayat kontak erat dengan orang yang dinyatakan Kasus Konfirmasi, Kasus Suspek, Kasus Probable,
Kontak Erat, Discarded, selesai isolasi dan kematian COVID-19 (berjabat tangan, berbicara, berada dalam satu
ruangan/ satu rumah)?
Do you have a history of close contact with people who are declared Confirmed case, Suspect, Probable, Closed contact, after
isolation, or death by COVID-19 (shake hands, talk, body touch or being in one room/ one house)?
Jika Ya, kapan (if yes, when)............................................................
Sebutkan (mention)..........................................................................

3. Apakah pernah mengalami demam/batuk/pilek/sakit tenggorokan/sesak/hilang indra pencium/hilang indra perasa?

Have you had a fever/cough/runny nose/sore throat/or tightness/loss of sense of taste and smell?
Jika Ya, kapan (if yes, when)............................................................
Sebutkan (mention)..........................................................................

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 Form: TKI-TFCov-02 Rev2
4. Apakah Anda pernah mengikuti kegiatan yang melibatkan orang banyak?
Have you ever participated in an activity that involved a lot of people?
Jika Ya (if Yes)
Pakai Masker Jarak
berapa lama berapa (wear mask) (distance)
Kegiatan/Acara Ya/Tidak
(paling lama) sering Kadang
(Activities/ Event) (Yes/No)
duration (how Selalu dibuka < >
(longest one) often) (always) (sometimes 1Mtr 1Mtr
open)
Pernikahan/ Pesta
(Wedding party)
Perkumpulan keluarga/ paguyuban
(Family association)
Tabligh Akbar/ Rohani lainnya
(spritual activities)
Demonstrasi
(demonstration)
Pemakaman
(funeral)
Tempat Wisata/ umum (seperti
pantai, taman, dsb)
(tourist place, beach, park, etc.)
Tempat keramaian lain seperti
kampanye, bioskop, dsb.
(Other crowded places such as
campaigns, cinemas, etc.)
Transportasi Umum
(Public transportation)
Satu kendaraan dengan orang yang
bukan tinggal satu rumah
(In a car with another person who
do not stay in same house )
Perjalanan ke luar kota Batam/
internasional/wilayah yang
terjangkit/ zona merah
(Travelled outside the Batam city/
international/affected area/ red zone)
Kegiatan lain di luar rumah TANPA
Masker, seperti: belanja di warung,
pengurusan dokumen
(Other activities outside your home
WITHOUT a mask, such as: shopping at
a shop, processing documents)
Kegiatan lain selain yang
disebutkan di atas (Other activities
apart from those mentioned above)

5. Apakah ada Anggota keluarga atau orang lain yang tinggal dalam satu rumah (misal suami, istri, anak, saudara,
kerabat atau yang lain) yang pernah atau mempunyai aktivitas rutin di luar rumah? (Ya/Tidak)
Are there family members or other people who live in the same house (eg husband, wife, children, siblings, relatives or others) who
have or have regular activities outside the home? (Yes No)

Hubungan (Relationship) Kegiatan (Activities) Berapa sering (How often) Tempat (Place)

Tanda tangan (Signature)

Tanggal (Date)

NOTE: FORMULIR INI DI ISI TERMASUK DENGAN KEGIATAN HARI LIBUR DAN MINGGU, DAN DI KEMBALIKAN KE
SECURITY DI GATE MASUK PADA HARI SENIN SAAT KEDATANGAN.
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