FORM 1

INSTRUMENTS OF SELF ASSESSMENT

RISK OF COVID-19

Name Setiadi Margono

: .................................
ID no/passport no. 3674062604870013
: .................................
Construction and Supervision
Group/PMC : .................................
Date : ...................................
02 Sep 2020

For the health and safety at work, you must be HONEST in answering the questions below.
In the past 14 days, have you experienced any of the following:

No Question Yes No If Yes, If No,

score score

1 Have you ever gone outside/gone to public place (market, 0 1 0

public health service, come to group of people, and
others?

2 Have you ever used public transportation? 0 1 0

3 Have you ever traveled for domestic/international? (to 1 0

affected area/red zone)
0
4 Have you participated on activities in crowd or involcing 0 1 0
many people?

5 Have you had a history to close contact with person in 5 0

monitoring (ODP), patient in monitoring (PDP) or positive
0
confimed affected COVID-19 (shake hand, talk, in the same
room/same house)?

6 Have you ever experienced fever/cough/flu/septic 5 0

throat/hard to breath in the past 14 days
0
TOTAL

0 = low risk
1-4 = moderate risk
>5 = high risk

FOLLOW UP:
- High risk, conduct investigation and not allowed to work. Worker need to be checked for RT-PCR, if not
possible can be checked with Rapid test by health worker/ local health service facility.
- Low risk to moderate risk, allowed to enter work but needs to carried out temperature check at the entrance
of the work site. If there is a temperature >37.3 °C to be investigated and examined by health workers. If
confirmed workers do not meet the criteria of OTG (person without symtomps), ODP or PDP. Workers can
come to work.

PT Witteveen Bos Indonesia is part of the Witteveen+Bos-group

Park View Plaza, 6th floor | Jl. Taman Kemang no. 27 | Kemang - Jakarta Selatan 12730 | Indonesia
t +62 21 719 12 82 | f +62 21 719 12 83 | www.witteveenbos.com
MLHR no. AHU-0132340.AH.01.11.Year 2018 | NIB no. 8120018190819 | NPWP no. 73.665.774.3-014.000