41. Kosambi Timur Raya No. 2 RT. 011/004 (Pertigaan Kosambi Timur - Barat) Kosambi Timur Kec. Kosambi, Tangerang 15213, Telp. 021 - 2903 1659 RS é RUMAH SAKIT Bun HASIL PEMERIKSAAN Penanggung — : UMUM Penanggung Jawab —_: dr. Fransisca Mulyadi, Sp PK ‘Alamat Dokter 4r. Kheluwis Sutiady NoRm/Ruang : 000050843 / - Lae 59735 /20109/2021 16:35 NoLab/Tal 29315 / 20/08/2021 17:10 sJeris Kelamin LAKLLAKI NemaPasien — : JALALUDIN TolLahir 15/02/2000 ‘Alamat KP. KAPLING Telepon Pemeriksaan Hasil NILAIRUJUKAN — Satuan KETERANGAN HONOLOGT covio 19 Rapid Covid 181g @ ‘Non Reaktit Non Reaktt Metode : Rape Antibo! Screening Hasi perrerisaan tsak Sapet [anit ehcp cea prow * Gs i aes pa eat uc ev reget Wipe mje mae Res Reh ee angie oe ya atic ae rk Va si Dea? = a Be pare pee M cew lr LA rg net erie? es fap a aa Ea wt capa eenpon ang aynan ODF, POP aaa tn COVIDTS (0G «¢_ fenoan. ecards dala st oagan ra? nee es Kal Ge Sel een ont psd peri (Cone re a eke he ere ace hese) esa ai el ema eR pop onal be a apron ee? 7 0 nese rh Yao la rane ¥ a [otal Score [bopan ni dit oleh HSE HMSI/ Tl or le fledn by the HSE of WMS] 2m wajbmelampirton Copy hes Rapid tex dg hall Non Reaktit/ Negatif yang mash bertaku, matsimal 14 hari seteah pengambilan sampel api) \cvests re required to attach 2 copy ofthe Rap st ests wih or Aeacve/ Megatv result (which ore stl val, «max. of 14 doys ter rapid sampling) Jnencana kurjungan dapat tak apie total iat mele ketertuan / The ws plan con be reece the atl value exceeds the provisions [Note i lah Formulitem nods/4 6 dengan lena / plese i the orm coreleely JTANDA TANGAN TAMU / Sign of Visitor Item o.1 until im roe i i 2 Kian ke HSE PTHMSL3 1 har sm kunjunga / send to HSE ofthe PLANS) [tar xcs ren eae 31 ys riot your vist MS aN: Email: Nuraddni@hno 0 Vstake) ‘Ms Marlin El: Matina@hina cod (MT) 2 Formalin brah? hat seaktangeal peng / Ts orn wali for 7 days ce ae omivedte off TID & ama Teng ign Vitor Nome IKOLOM INI DISI OLEH PENGUNDANG / This Coloumn i fled in by Inviter Keputusan /Decission ma engin oe =) Ip, J Aas Di. Head) tnar engin Formal /0eteofSabmisionform = inungan Diterima / Ditolak* fonds Tangan Keo. Ov | Dv Heed sgnture Accepted / Denied* Joneraun oan nse Hse crootesge scone tisk pers /Cossunnecesory Dipindai dengan CamScannereS ‘cin Derton orm to Prev Con 18 Ed BAGIAN INLDIISI OLEH TAMU. Nama /Name Jelaudin [Nam Perusahaan / Company Nome 1%, Cyn Ulm Peotn No. Passpart/Pasport No, Smeameraeimed iC tack Dis / Dis ate Dean Kesehatan dan Keselamacan ben ras JUIUR menjawal dengan menting (YA TDK ilo jaan awa ue safety earn, please hone hee questions Below by eons the anewer (YES/NO) itera kr, Dalam 14 arf terakhir,apakah anda pernah mengalani hal-ba bent Inthe lass 14 Days, have you ever been in this station TAWARAN NO PERTANYAAN ANSWER OURSTION Ya | TIDAR ves No paps lar wma cpa un pasar, RS, Puaenas ain, an Koruna orang de nny)? = AD | cewven he pal ror, kp ca, eral mor brea? | @ pata 1 ta tabi peoah mena wanna ome? ree [tare ou ne puberanpor in heat 14 ays? I Fags penal ela prjlnan Kast klar ngs? Wilyah yang vejanp i” Yoma wah? oi Have vow ever een abroad tater cies cer coinfection ne? ats dk ge eis sli ga TD? a eS [ave ou participate m actives which muon more than 20 peoples? apa mera rwayar Kowa rat dengan orang -rang yang dings ODP, POP. atau Koon COVID-19 (Baba T nan, erbcara, era dal st angst rumah)? # > Ive sou had eotac to Cove infected perom, Covi Supecedperion ? (Comat throug hand sha, ak been i he ss lame room / same house) [pst satin au dal ha er anda pera ial ena BaX paki gpa aps? = aS [ave you get fever fought aor threat hard breathing? C frotal score [bogian in dsl oleh HSE HMSI/ This Parts fled in by the HSE of HMI] frarmu wail melsmpirkan Copy hl Rapid tes dg has Non Reaktit/ Negatif yang mash beraku, maksimal 14 hari setelah pengambilansampel 2p) |Gucsts ore ewsived to attach copy ofthe Rapid test results wth Non Reactive /Negotve revit which oes vol max of 14 days after rps sana) Jnencanakunjungan dapat ditlatapabla total nil melebhiketentan The ws pan canbe rejected ifthe ttol vale exceed the provisions TTalah Formulr tem no 1 o/4 dengan lenglap [pease ithe form comaleiely [TANDA TANGAN TAMU / Sign of Visitor Items nod onti6 lenin tt nt 22 Kean ke HSE PMS 3-1 har sbi hnjungan/ send 10HSE ofthe PAs [weno emma mr wre 351 doy prio to your st ‘Ms ka W E-mail ha Nuraddin\@hino.coid lata) fs Marla: Email: Marina@hina cod (MT) 3 Form in bela 7 hat sak angal pengslan / This form wll fr 7 days oe Irom the de of ing TTD& Wana Tang sgn 8 Vator Nome [kOLOM INI DIIs| OLEH PENGUNDANG / This Coloumn is filled in by Inviter Keputusan / Decision ee ‘orang lama Pngunane/ tenn Eee) oa Jrermattep Atta eas) Diterima / Ditolak* [onto Tongan Hep Om. 0 Head Sonne Accepted / Denied* Jobe olen HS / HS enone cove yp tisk pths/ ross unecessary Dipindai dengan CamScanner