Document Number

FORM 001/FRM/RISINT-CRI/I/2021

Date 12 Jan 2021 Revision 0

Page 2 pages CRI Prev 0

Version

ON THE JOB FORM

All personnel who will conduct any activities which involve face to face contact with external personnel will
be required to fill this form before execution of the activities/ job. Failure to do so will result in sanction.
Each personnel should fill and obtain approval prior to execution of the activities/ job.

Name Herwan Agus Suhendra

Position Response Team / Bandar Lampung

Region/ Base/ Unit Sumbagsel / Bandar Lampung

Email Herwanindra123@gmail.com

Telephone 082186668641

Employee ID No 01310203284

Current Working Period Non rotasi

Form Date

Self Assessment

Fever ≥ 37.5℃ / Demam ≥ 37.5℃ ❏ Yes ❏ No

Flu / Flu ❏ Yes ❏ No

Cough / Batuk ❏ Yes ❏ No

Breathing Problem / Gangguan Pernafasan ❏ Yes ❏ No

Loss of Taste/ Smell / Kehilangan Indera Rasa/ Penciuman ❏ Yes ❏ No

Sore Joint / Sakit Persendian ❏ Yes ❏ No

Extreme Fatigue / Kelelahan ❏ Yes ❏ No

Digestive Problem / Masalah Pencernaan ❏ Yes ❏ No

Job Assessment

Job Category
 Document Number
FORM 001/FRM/RISINT-CRI/I/2021

Date 12 Jan 2021 Revision 0

Page 2 pages CRI Prev 0

Version

Job Date/ Time

Location/ Positivity Rate

Place/ Health Protocol

Assessment

Est. External Personnel Number

Est. Job Period (Start - Finish)

Protection Kit ❏ Mask ❏ Hand Sanitizer ❏ Wet Tissue

List of Personnel in Contact

Approval

Personnel 1st Approval 2nd Approval

Herwan Agus Suhendra Indra Sakti Denny Heryanto Nainggolan

Response Team Regional Coordinator RRIM