HEALTH DECLARATION FORM

(FORM DEKLARASI KESEHATAN)

Name (Nama) : ……………………………………………..

Company (Perusahaan) : ……………………………………………..
Nationality (Kebangsaan) : ……………………………………………..
Visit Period (Rencana Kunjungan) : ……………………………………………..
Needs (Keperluan) : ……………………………………………..
Polytron PIC (PIC di Polytron) : Tim Vokasi - PCCA

Health History (within 14 Days)

Yes No
1. Have fever history exceeded 37.3°C
(Pernah mengalami demam > 37.3°C)
2. Have cough and/or cold history
(Pernah mengalami batuk dan/atau flu)
3. Have Pneumonia / Difficult in breathing history
(Pernah mengalami sesak nafas)
4. Have sore throat history
(Pernah mengalami radang atau sakit tenggorokan)

Journey History (within 14 Days)

Yes No
5. Have travelled history to COVID-19 risk areas that defined as
level 3 or level 2 risk by the Centers for Disease Control and Prevention (CDC)
(Pernah melakukan perjalanan ke area yang terjangkit COVID-19
sebagai area level 3 atau level 2 oleh CDC)
6. Have contacted with Corona Virus sufferers
(Pernah berkontak langsung dengan penderita virus corona)

Polytron Date: / /
Checked By, Sincerely,

User / PIC Visitor

Note:
1. This form must be filled in accordance with your condition by put (X) mark in the columns.
2. This form must be submitted to Polytron PIC by the latest 7 days prior to your arrival to Polytron,
If there is any delay of form submission, the form will not be processed.
3. Kindly cancel your visit to Polytron if you get one of the situation as mentioned before.
4. Kindly print out and bring this signed form on your visit.

Permitted Not Permitted