OPERATION

Doc. No. : HCML.OPR.HSE.FRM.001

DAILY QUARANTINE REPORT Doc. Level : 4

GENERAL DATA
Employee Name : Dani Kurniawan Employee Number :
Field Location : HCML Sampang shorebase Rooster Group (A / B / C) :
Jalan Raya Daendels , Desa,
Current Date : 31 Januari 2021 Tanjung Pakis, Kemantren, Paciran,
Quarantine Location (Adress):
Quarantine Day : 5 of 7 Lamongan Regency, East Java
62264i
TRAVELING RECORD & PLAN

3 Febuari 2021: Inspeksi & color code Equipment OSCT (Gresik - HCML Sampang
Travel History for 14 Days:
Shorebase)

Plan to Travel Outside Quarantine Zone Today Yes No Already Inform Dept. Manager for Travel Plan? Yes No N/A

Reason for Travelling (If any) N/A

HEALTH CONDITION
Temperature Measurement (oC) Day 36 Afternoon 36,5 Night 36,2
General Health Condition Well Unwell
Symptomps Yes No
Fever
Checklist for any Symptomps Cough
Sneeze
Shortness of Breath

Remarks

STATUS OF FAMILY & OTHER PEOPLE LIVING TOGETHER

General Health Status of Family & Other People Living Together
All in health condition
(Please write general remarks, including any symptomps of the people live together)

Travel History of the Pople Living Together within 14 days

No travel
(write down general remarks)
Activities Record
State Your General Daily Activities
Wake Up Time - 08.00 AM Breakfast, general clean up, morning shower

08.00 AM - 12.00 PM Excersie

12.00 PM - 15.00 PM Lunch, praying

15.00 PM - 18.00 PM Evening shower, praying

18.00 PM - Sleep Time Dinner, Sleeping

Video Reporting Checklist 07.00 10.00 13.00 16.00 19.00
Daily Movement Tracking
(attach your screen capture of Google Map Daily Movement Tracking Here, up to 07.00 PM everyday)

31 Januari 2021

Approver Signature

Originator Name : Dani Kurniawan Signature Date : 31 Januari 2021

Approver 1
Name : Asep Sudrajat Signature Date : 31 Januari 2021

Approver 2
Name: N/A Signature N/A Date : N/A