HEALTH

CHECKLIST

TEMPERATURE: 36,2 oC

NAME (NAMA): IRMAN

SEX (JENIS KELAMIN): LAKI-LAKI AGE (USIA): 27 TAHUN
RESIDENCE (ALAMAT): KARAWANG BARAT

I. In last 14 days, did you experience the following :

(Dalam 14 hari terakhir, apakah anda pernah mengalami hal berikut 
Filled by HR
QUESTIONS YES NO
IF YES, IF NO,
SCORE SCORE
1. Are you experiencing fever/cough/runny 1 5 0
nose/sore throat/shortness of breath ?
(Apakah anda mengalami
demam/batuk/pilek/sakit
tenggorokan/sesak?)
2. Have you had any contact with anyone 1 5 0
with people who declared ODP, PDP, or
confirm COVID-19? For example shaking
hands, talking, being in one room or one
house
(Apakah memiliki riwayat kontak erat
dengan orang yang dinyatakan ODP,
PDP, atau confirm COVID-19 ? Misalkan
berjabat tangan, berbicara, berada
dalam
satu ruangan atau satu rumah)
3. Have you ever left the house of go to 1 1 0
public place? Such as market, hospital
(Apakah anda pernah keluar
rumah/ke
tempat umum?)
4. Are you using public transportation? 1 1 0
(Apakah pernah menggunakan
transportasi umum?)
5. Have you travelled outside the 1 1 0
city/international to the affected area/red
zone?
(Apakah pernah melakukan perjalanan
ke luar kota/internasional ke wilayah
yang
terjangkit/zona merah)
6. Do you participate in activities that involve 0 1 0
a lot of people?
(Apakah anda mengikuti kegiatan yang
melibatkan orang banyak?)
JUMLAH TOTAL
II. Do you currently have a history of the disease below?
(Apakah saat ini memiliki riwayat penyakit dibawah Ini ) :

 Hypertension (Hipertensi)  Asthma (Asma) √

 Diabetes (Diabetes Melitus)  Cancer (Kanker)

 Heart Disease (Penyakit Jantung)  Immune Disorders (Gangguan Imun)

 Chronic Obstructive Pulmonary  Tuberculodid (TBC)

Disease (Penyakit Paru Obstruktif  Liver Disease (Penyakit Hati)
Kronis)

 Kidney Disease (Penyakit Ginjal)

 Breath Disorders (Gangguan Nafas)

SCORE :
0 = Low risk
1–4 = Moderate risk
≥5 = High risk

Follow-up :
 A high risk, to be investigated and not allowed to come to work. Workers undergo an
RT- PCR examination, if not available, a Rapid Test can be carried out by a local health
worker / health facility
(Resiko besar, agar dilakukan investigasi dan tidak diperkenankan masuk bekerja.
Pekerja dilakukan pemeriksaan RT-PCR, jika tidak tersedia dapat dilakukan Rapid
Tes oleh petugas kesehatan/fasyankes setempat)

 Low risk - moderate, allowed to enter work, but temperature checks are performed at the
workplace entrance. If a temperature of ≥ 37.3 oC is obtained, an investigation and
inspection by a health worker is required. If it is confirmed that the worker does not meet
the criteria of OTG, ODP, or PDP, the worker can enter work
(Resiko kecil – sedang, diperbolehkan masuk bekerja namun dilakukan pemeriksaan
suhu di pintu masuk tempat kerja. Apabila didapatkan suhu ≥ 37,3 0C agar dilakukan
investigasi dan pemeriksaan petugas kesehatan. Jika dipastikan pekerja tidak memenuhi
kriteria OTG, ODP, atau PDP, pekerja dapat masuk bekerja.)

I hereby authorize TRIPUTRA PERSADA HORIZON EDUCATION, to collect and process the
data indicated herein for the purpose of effecting control of the COVID-19 infection.

Signature: Date : 28 JUNI 2020