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  • Health Declaration NSI Employees Form Maret

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    This document is a health declaration and monitoring form from PT. Nippon Shokubai Indonesia. It contains health information for an employee named Rudihen over a 14 day period including temperature readings, symptoms like fever, headache and cough. The employee declares their health condition each day. The form is used to monitor the health of employees returning from travel outside Indonesia or new expatriates/visitors as a precaution during the COVID-19 pandemic.

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    This document is a health declaration and monitoring form from PT. Nippon Shokubai Indonesia. It contains health information for an employee named Rudihen over a 14 day period including temperature readings, symptoms like fever, headache and cough. The employee declares their health condition each day. The form is used to monitor the health of employees returning from travel outside Indonesia or new expatriates/visitors as a precaution during the COVID-19 pandemic.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    Download as pdf or txt
    14 views2 pages

    Health Declaration NSI Employees Form Maret

    Uploaded by

    rudihen
    This document is a health declaration and monitoring form from PT. Nippon Shokubai Indonesia. It contains health information for an employee named Rudihen over a 14 day period including temperature readings, symptoms like fever, headache and cough. The employee declares their health condition each day. The form is used to monitor the health of employees returning from travel outside Indonesia or new expatriates/visitors as a precaution during the COVID-19 pandemic.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 2

    PT.

    NIPPON SHOKUBAI INDONESIA


    Health Declaration and Monitoring Form
    (This Form shall fill by NSI employee from traveling outside Indonesia, Candidate Expatriate to NSI and Approved TA/SV from Nippon Shokubai Group before
    go out from airport building)

    Name : Rudihen
    NIK : 1660
    Department/Project : Production SAP
    Trip from : …—…………………………………………………… (Country Name)
    Enter Date to Indonesia : …-……………………………………………………………

    Herewith I declare that my health condition as below :


    Difficult to Tasty & Smell
    Body Temperature Fever Headache Cough Sore Throat
    breath a Condition
    Day of Filling Date Suhu Badan
    Suhu Badan Kesulitan Sakit Keluar air dari Rasa dan
    Afternoon/ Demam Kepala Sakit Batuk
    Morning/ Pagi bernafas Tenggorokan hidung Penciuman
    Sore

    1st ‘13/Mar/2021 36.6 NO yes NO NO NO NO OK

    1st ‘14/Mar/2021 35.7 36.7 NO NO NO NO NO NO OK

    3rd 15/ Mar/ 2021 37.0 36.7 NO NO NO NO NO NO OK

    3rd 16/ Mar/ 2021 35.4 NO NO NO NO NO NO OK

    5th

    6th

    7th

    8th

    9th

    10th

    11th

    12th

    13th

    14th

    Notes:

    Cilegon,………………………….2020

    ( ……..…………………….. )
    Name :

    * (After 14 days monitoring)


    HC-LTR-06-01, 24-Feb-20
    PT. NIPPON SHOKUBAI INDONESIA
    Health Declaration and Monitoring Form
    (This Form shall fill by NSI employee from traveling outside Indonesia, Candidate Expatriate to NSI and Approved TA/SV from Nippon Shokubai Group before
    go out from airport building)

    Name Dian Naili Marufah


    NIK
    Department/Project :
    Trip from : …—…………………………………………………… (Country Name)
    Enter Date to Indonesia : ……………………………………………………………………

    Herewith I declare that my health condition as below :


    Difficult to Tasty & Smell
    Body Temperature Fever Headache Cough Sore Throat
    breath a Condition
    Day of Filling Date Suhu Badan
    Suhu Badan Kesulitan Sakit Keluar air dari Rasa dan
    Afternoon/ Demam Kepala Sakit Batuk
    Morning/ Pagi bernafas Tenggorokan hidung Penciuman
    Sore

    1st ‘13/Mar/2021 36.6 NO yes NO NO NO NO OK

    1st ‘14/Mar/2021 36.5 36.8 NO NO NO NO NO NO OK

    3rd ‘15/Mar/2021 36.1 36.2 NO NO NO NO NO NO OK

    3rd ‘16/Mar/2021 35.6 NO NO NO NO NO NO OK

    5th

    6th

    7th

    8th

    9th

    10th

    11th

    12th

    13th

    14th

    Notes:

    Cilegon,………………………….2020

    ( ……..…………………….. )
    Name :

    * (After 14 days monitoring)


    HC-LTR-06-01, 24-Feb-20

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