PEMERINTAH KABUPATEN PROBOLINGGO

RSUD WALUYO JATI KRAKSAAN

Jl. Dr. SoetomoNo.1Telp.(0335) 841118,841481,Fax (0335) 841160
KRAKSAAN – PROBOLINGGO – 67282
Website : www.rsudwaluyojati.Probolinggokab.go.id E-mail: rsudwaluyojati@Probolinggokab.go.id

INFORMED CONCENT FOR ACTEMRA UN – LICINSED INDICATION

Hospital RSUD WALUYO JATI KRAKSAAN Hereby Certify that :

The Purchase order to PT. Tempo For Product Actemra 400 mg. 2 vial ( as per purchase order number
PO210800014 as : per-attached) is intended for treatment of hospitalized patient with severe COVID-19 patients.

Patient Initial (s) : Ny. N

Treating Physician (s) : dr. Resyana Widyayani, Sp.An ( 081327719992 )

Hospital RSUD Waluyo Jati Kraksaan is fully aware that the usage of drugs as mentioned above is for an
unlicensed indication Indonesia.

Hospital Authorized Person,

Name : Rokayah, S.Si., Apt ROKAYAH, S.Si.,Apt
446/0020/SIPA/426.116/2021
Title : Apoteker Penanggung jawab RSUD Waluyo Jati Kraksaan
Date : 05 Agustus 2021

(In Indonesia. Actemra (Tocilizumab) is approve by BPOM for Rheumatoid Arthritis (RA), Polyarticular
Juvenile Indiopathict Arthritis (pJIA), and Systemic Juvenile idiopathic Arthritis (sJIA). It is not approved for the
treatment of fiospiialized COVID-19 patients. As evaluating the risk-benefit profile of Actemra use is important
for Patient Safety Risk management, Roch encourage HCP to report the use of Actemra in COVID-19 patients
and is adverse event through online form: https://cf>rt roche.com/a contact Roche
Patient Safety atindonesi&safetyr@rovhe.com].
Jl. Dr. Soetomo No.1
[‘ SURAT PESANAN
Telp.(0335) 841118,841481,Fax (0335) 841160

No. Pesanan : PO05082021 Supplier : TEMPO

Tgl. Pesanan : 05 Agustus 2021 Unit Pemesanan : Gudang Farmasi
Kepemilikan : UMUM
Hal. 1 dari 1

No. Nama Barang Jml. Pesan Satuan Keterangan

1 Actemra 2 vial

Petugas Input : LUKI HARJANTI, S.Farm.,Apt

Tgl Cetak : 05/08/2021 12:20 / LUKI HARJANTI, S.Farm.,Apt