INSAN CENDEKIA MADANI South Tangerang, February 3, 2022 No.: 051/B/ICMIPS/IV/2022 ‘Subject: Second Dose Covid-19 Vaccination Activities Notification ‘Attachment: Vaccination Statement Letter and Screening Form Dear Parents of ICM Primary School Program Assalamu/alaikum Warahmatullahi Wabarakatuh, Praise Allah SubhanahuWatalala, who has given us various blessings to do our daily activities well. Therefore, shalawat and salam shall be poured to the Prophet Muhammad Shalaliahu’ Alaihi Wassalam, along with his families, friends, and followers. Regarding the schoo! collaboration with the Public Health Centre (Puskesmas), which is based on the Banten Provincial Health Office reference letter No: 005/4043/KES-P2P/XII/2021, about the COVID-19 vaccination for children aged 6-11 and based on the availabilty of time at the Rawabuntu Public health Center, we want to inform you of the vaccination activities (second dose), the estimated time for vaccination activities will be held on Thursday, February 17, 2022, at Sekolah ICM for all grades 1-6 students Related to the vaccine activity, we would like to inform the following: 1. All students are learning at home 2, All students are dropped off and picked up by their parents or representative and waiting for students in their vehicles. 3. The vaccine activity schedule is as follows: Class. Time Grade 1&2 830-930 AM Grade 3&4 9.30 - 10.30 AM Grade 5 10,30 - 11.30 AM Grade 6 12.30- 13.30 Soe Jin. Ciater Raya (H.Amat) Kampung Maruga RT 05/Rw 09 | Ciater | Serpong | Tangerang Selatan Hotline :021 7587 4444 | Fax. 021 756 6852 | www.icm.schidINSAN CENDEKIA MADANI ‘Therefore, we would like to ask you to fill out the Parents’ Consent Form to inform your permission for your child. to undergo this vaccination process and vaccination screening form (part A and part B — questions 1-9) as a background check assist vaccination services. In addition, please bring a copy of the updated Family Card- Based Citizenship and Civil Registration (Dukcapi) (Kartu Keluarga), Vaccine card/Vaccine certificate during the day of the vaccination process. ‘Should you have any questions, please feel free to email us at primaryadmin@icm.sch.id. We thank you for your continuous suppor, attention, and kind cooperation. May Allah bless all of us. Stay safe and healthy. ‘Wassalamu’alaikum Warahmatullahi Wabarakatuh, Primary School Program Principal Jin. tet Raya (H.Amat) Kampung Maruga RT 05/Rw 09 | Ciater | Serpong | Tangerang Selatan Hotline :021 7587 4444 | Fax. 021 756 6852 | www.icm.sch.id2 INSAN CENDEKIA MADANI PARENTAL CONSENT LETTER Second Dose COVID-19 Vaccination ‘The undersigned below Parents’ Name Student's Name. Grade We confirm that we ALLOW/ NOT ALLOW’ our child to have second dose COVID-19 vaccination on February 17, 2022. We understand that everything that happens due to the effects of COVID-19 vaccination is beyond the school's responsibility. ‘Thus, we make this statement in truth and without coercion from any party. South Tangerang, 2022 om Parents Signature *Cross the unnecessary optionFORMAT SKRINING PELAYANAN VAKSINASI COVID-19 BAGI ANAK USIA 6 (ENAM) SAMPAI DENGAN 11 (SEBELAS) TAHUN A RUANG TUNGGU ‘Nama NIK ‘Tanggal Lahir No. HP ‘Alamat Vaksin yang diberikan padadosis 1 “NIK didasarkan pada data DUKCAPIL 8. MEJA 1 (SKRINING DAN VAKSINASI) No | Pomeriksaan Kasil | __Tindak Lanjut 1 | Suhu | Suhu > "37,5 °C vaksinasi ditunda sampai sasaransembuh 2 | Tekanan Darah Tika tekanan darah >140/100 mmHg | pengukuran tekanan darah diulang 5 (lima) sampai 10 (sepuluh) meni kemudian. Jika masih tinggi maka vaksinasi ditunda dan dirujuk Pertanyaan Ya | Tidak 1 | Apakah anak mendapat vaksin lain (vaksin rutin) kurang dari 2 minggu sebelumnya? Jika Ya, vaksinasi ditunda 2 | Apakah anak pernah sakit COVID-197 Jka Ya, untuk derajat ringan dansedang vaksinasi ditunda 1 bulansetelah sembuh Untuk derajat berat vaksinasi ditunda 3 bulan setelah sembuh 3 | Apakah dalam keluarga terdapat kontai Jika ada Kontak, vaksinasi di tunda 2 dengan pasien COVID-197 minggu | Apakah dalam anak menderita demam atau batuk pilek atau nyeri menelan atau muntah atau diare? Jika Ya, _vaksinasi ditunda,dianjurkan untuk berobat| Apakah dalam 7 hari terakhir anak pernah Jika Ya, vaksinasi ditunda, dianjurkan mendapat perawatan di RS atau untuk berobat menderita kedaruratan _medis seperti sesak napas, kejang, tidak sadar, berdebar-debar, perdarahan, hipertensi, tremor hebat? 6 | Apakah anak sedang —_ menderita Jka’ Ya, vaksinasi ditunda, sampai ‘gangguan imunitas (hiperimun: autoimun, inkan oleh dokter yang merawat alergi berat dan defisiensi imun: gizi buruk, HIV berat, keganasan)? 7 | Apakah saat ini anak sedang menjalani Jika Ya, vaksinasi_ ditunda, sampai Pengobatan imunosupresan jangka diizinkan oleh dokter yang merawat Panjang (steroid lebih dari 2 minggu, sitostatika)? 8 | Apakah anak mempunyai riwayat alergi Jika Ya, vaksinasi disarankan dirumah berat seperti sesak napas, bengkak, sakit Urtikaria di seluruh tubuh atau gejala syok anafilaksis (tidak sadar) setelah vaksinasi sebelumnya? 9 | Apakah anak penyandang penyakit Jika Ya, vaksinasi disarankan dirumah hemofilia/kelainan pembekuan darah? sakit HASIL SKRINING : Paraf petugas: LANJUT VAKSIN TUNDA TIDAK DIBERIKAN Jenis Paraf petugas: \Vaksin: No. Batch Tanggal vaksinasi Jam Vaksinasi | ¢. MEJA 2: PENCATATAN DAN OBSERVAS! “Tanpa kelunan ‘Ada keluhan ‘Sebutkan keluhan jika ada, Paraf petugas: