Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.

Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
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 Form No: EHS/FR/391-00
TRACING ABSENT FORM
Outbreak Form 1B Medical Background Check - Visitor/ Vendor/ Supplier/ Contractor Health Declaration
Formulir Kejadian Luar Biasa 1B Pemeriksaan Riwayat Medis - Pernyataan status Kesehatan Tamu/Vendor/Suplier
Tanggal : _______________ Nama Supir : _______________
Note: *) Put an X mark in your chosen box
Keterangan Berikan tanda silang (X) pada kotak pilihan Anda
Nama Petugas : _______________ No Body Bus : _______________
IDENTITY / IDENTITAS
NAME :
KPK : _______________ Tiba di PTMI : _______________
Nama

ID NUMBER : COMPANY NAME : Rute : _______________ Jumlah penumpang : _______________

No KTP Nama Instansi

GENDER*) MALE FEMALE Shift : _______________ Masuk kerja (jam) : _______________

Jenis Kelamin *) Laki-laki Perempuan

ADDRESS
Alamat :

CONTACT EXPOSURE FACTOR / FAKTOR KONTAK PAPARAN

Do you have travel history 14 Days
prior to the illness? YES NO
Apakah Anda memiliki riwayat perjalanan Ya Tidak
dalam 14 hari sebelum mengalami sakit?
If YES, where did you go? Date of Arrival in Indonesia
Bila YA, sebutkan ke manakah Tanggal kedatangan di Indonesia
tujuan Anda? / /
Date/Month/Year / Tanggal/Bulan/Tahun

Within 14 days before the illness, did you have a close contact with
2019-nCoV suspected/confirmed person? *) YES NO UNKNOWN
Dalam 14 hari sebelum sakit, apakah Anda memiliki kontak erat dengan Ya Tidak Tidak Tahu
kasus suspek/yang terkena virus 2019-nCoV? *)

HISTORY OF ILLNESS / RIWAYAT PENYAKIT

Are you having a symptom of common cold? *) YES NO If Yes, since when?
Apakah Anda sedang mengalami gejala flu? *) Ya Tidak Jika Ya, sejak kapan?
/ /
Date/Month/Year / Tanggal/Bulan/Tahun
Are you having below symptom(s)?
Apakah Anda sedang mengalami gejala di bawah ini?
*) *)
Fever YES NO Sore throat YES NO
Demam *) Ya Tidak Sakit tenggorokan *) Ya Tidak
*) *)
Cough YES NO Shortness of breath YES NO
Batuk *) Ya Tidak Sesak nafas *) Ya Tidak
*)
Cold YES NO
Pilek *) Ya Tidak

I certify that the above information is to the best of my knowledge and correct belief. I concent to the results of this form
being stored in paper and electronic format. I am willing to follow the Company policy regarding outbreak preparedness
and if required, I'm willing that my medical information may be released to the Company Management.
Saya menyatakan bahwa informasi yang saya sampaikan di atas adalah sebenar-benarnya dan sesuai dengan
pengetahuan saya. Saya menyadari bahwa hasil yang dituliskan dalam formulir ini disimpan dalam bentuk kertas dan
elektronik. Saya bersedia mengikuti kebijakan Perusahaan terkait antisipasi wabah dan jika diperlukan, saya bersedia
bahwa informasi kesehatan saya akan diserahkan kepada Manajemen Perusahaan untuk digunakan sebagaimana
mestinya.
Note :
Mandatory requirements for all Visitors / Vendors:
1. Prepare a mask before entering PT, Mattel Indonesia, sediakan masker sebelum masuk area PT. Mattel Indonesia.
2. Use a mask while in the PT. Mattel Indonesia, gunakan masker selama berada di area PT. Mattel Indonesia.
3. PT. Mattel Indonesia does not provide masks for guests or vendors. PT. Mattel Indonesia tidak menyediakan masker untuk tamu/vendor

FULL NAME & SIGNATURE

Nama Jelas & Tanda Tangan

Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
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Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
Mattel Confidential Information – Do Not Distribute – ©2021 Mattel, Inc. All Rights Reserved.
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