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  • Instrument Self Assesment

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    Annissa
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    This document is an instrument self-assessment for COVID-19 risks that asks employees to honestly answer questions about their activities and health over the past 14 days. It asks if they have traveled to red or black zones, attended large gatherings, taken public transportation, had close contact with suspected COVID-19 cases without protective equipment, or experienced symptoms like fever or cough. Employees are asked to provide their name, ID number, and unit before completing the self-assessment.

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    Self assesment

    Original Title

    INSTRUMENT SELF ASSESMENT

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    This document is an instrument self-assessment for COVID-19 risks that asks employees to honestly answer questions about their activities and health over the past 14 days. It asks if they have traveled to red or black zones, attended large gatherings, taken public transportation, had close contact with suspected COVID-19 cases without protective equipment, or experienced symptoms like fever or cough. Employees are asked to provide their name, ID number, and unit before completing the self-assessment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views1 page

    Instrument Self Assesment

    Uploaded by

    Annissa
    This document is an instrument self-assessment for COVID-19 risks that asks employees to honestly answer questions about their activities and health over the past 14 days. It asks if they have traveled to red or black zones, attended large gatherings, taken public transportation, had close contact with suspected COVID-19 cases without protective equipment, or experienced symptoms like fever or cough. Employees are asked to provide their name, ID number, and unit before completing the self-assessment.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    INSTRUMENT SELF ASSESMENT

    RESIKO COVID 19

    NAMA :
    NO. KTP :
    NO ID STAFF :
    UNIT :
    TANGGAL :

    Demi kesehatan dan keselamatan bersama ditempat kerja, anda harus JUJUR dalam menjawab
    pertanyaan dibawah ini.

    Dalam 14 hari terakhir apakah anda pernah mengalami hal-hal berikut ini :
    No Pertanyaan Ya Tidak
    Apakah pernah keluar rumah atau ke tempat umum (pasar,
    1. fansyankes, kerumunan orang, dll) tanpa menggunakan masker
    (baik masker bedah ataupun masker kain) ?
    Apakah pernah menggunakan transportasi umum (meskipun
    2.
    menggunakan masker) ?
    Apakah anda pernah melakukan perjalanan keluar
    3. kota/internasional (wilayah yang terjangkit ZONA MERAH atau
    ZONA HITAM) ?
    Apakah anda mengikuti kegiatan yang melibatkan banyak orang
    4.
    (meskipun menggunakan masker) ?
    Apakah memiliki riwayat kontak erat dengan orang yang
    5. dinyatakan ODP, PDP, dan terkonfirm COVID-19 TANPA
    menggunakan APD sesuai standar saat bekerja ?
    Apakah pernah mengalami demam/batuk/pilek/sakit
    6.
    tenggorokan/sesak dalam 14 hari terakhir ?
    JUMLAH

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