PT. Gajah Tunggal Tbk.

Health Screening Questionnaire

At PT. Gajah Tunggal Tbk., the safety and health condition of our employees, families and visitors
are always our first priority. As the outbreak of COVID-19 in many countries, Health and Safety
Environment (HSE) Department appoints Klinik Gajah Tunggal to monitor closely and update the
company’s prevention guidance based on recommendations from the World Health Organization and
Kementerian Kesehatan Republik Indonesia (Ministry of Health of Republic of Indonesia).

To prevent the widespread of COVID-19 and to reduce the potential risk of exposure to our
employees and visitors, Klinik Gajah Tunggal are conducting a simple screening questionnaire.
Your participation is important to help us take precautionary measures to protect you and everyone in
this building, plant or meeting event. Thank you for your cooperation.

Visitor Name:
Nationality:
Company/Organization:
Visitor Contact Number:
Contact Person from GT:
Building/Plant:

Kindly answer these following questions, based on your current health condition.

1 Did you visit any countries infected by COVID-19 within the last 14 days?
(Please refer to the attached list).
□ Yes □ No
2 Have you had close contact with or cared for someone diagnosed with COVID-19 within the
last 14 days?
□ Yes □ No
3 Have you experienced high body temperature/fever more than 37.3° Celsius in the past 3
days?
□ Yes □ No
4 Have you experienced any cold or flu-like symptoms within the last 14 days?
(including sore throat, cough, respiratory illness, breathing difficulty)
□ Yes □ No
Visitor Signature :__________________ Date :_____________________________

Note:

1. If you intend to stay onsite for several days, please immediately advise your host at PT. Gajah
Tunggal Tbk., if you experience any symptoms mentioned above.
This questionnaire will be used as reference to evaluate your access into GT facilities.
2. Please use mask for your self-protection, during your visit in GT facilities.
3. Please confirm whether you have already received Health Alert Card (HAC) upon your
arrival at any Indonesian airport.

Access to PT GT Facility Approved by Denied by