Form Data Peserta Rapid Test

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DATA PESERTA RAPID TEST

Nama : …………………………………………………………………………..

NIK : …………………………………………………………………………..

Alamat KTP : …………………………………………………………………………..

Alamat Domisili : …………………………………………………………………………..

No. HP : …………………………………………………………………………..

Pekerjaan : KS / Guru / Admin / Keamanan / Kebersihan * (pilih salah satu)

Sekolah tempat bekerja : ………………………………………………………………

Pekerjaan Tambahan : ………………………………………………………………

Riwayat bepergian 2 minggu terakhir :

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

Kegiatan / kebiasaan 2 minggu terakhir :

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

Penyakit yang diderita/Riwayat Penyakit :

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

- ……………………………………………………………………………………………….

Surabaya, Juni 2020

Peserta,

____________________________

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