Health Declaration Form

HEALTH & TRAVEL DECLARATION FORM

Dear Valued Guest,

You are kindly requested to fill out this Health & Travel Declaration Form of which is a mandatory procedure in accordance with Regional Government regulations in relation of the Covid-19 pandemic scenario and in response to any possible emergency, safety of others and comittment to track and trace and eliminate a spreading of this desease. Thank you for your understanding and cooperation.

Full Name (required)

Nationality (required)

Mobile No (required)

Your Email (required)

Room No (required)

Check In Date (required)

Check Out Date (required)

Last Country of Disembarkation (required)

Flight No

Temperature recorded (required)

Date Check (required)

Time Taken (required)

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Screening Questionnaire

1.Have you been admitted in a hospital in the past one month?
Yesno

If yes, please describe reason for admission and in which country

2.Do you have any flu like symptoms?
FeverYesno
CoughYesno
Sore ThroatYesno
BreathlessnessYesno
Runny NoseYesno
No Sense of Smell/No TasteYesno

Others, please specify

If you have answered ‘Yes’ to any of the symptoms above, we insist that you wear a mouth mask which are available at the Front Desk and we advice to consult a doctor for your own safety.

3.Have you been in quarantine in the past 3 months as of relating matters of COVID-19?
Yesno

4.Have you been in the past 2 months in contact with family members, relatives,
friends, business associates who have/had been infected with COVID-19?
Yesno

5.Have you and your travel partner or family travelled through any of the following listed Indonesian Provinces and Cities or Countries in the last 30 days?
East- & Central-Java; South-Kalimantan; South-Sulawesi; Jakarta, Surabaya?
Yesno
China, Singapore, Malaysia, Thailand, Europe, USA, Brazil, Middle-East, Iran, India?
Yesno
If ‘Yes’, please circle or underline the country or specify if any other

6.Have you been in contact with any of the following confirmed cases of infectious diseases in the last 14 days?
COVID-19Yesno
SARS-CoVYesno
EBOLAYesno
SWINE FLUYesno
MERS-COVYesno
BIRD FLUH5N1Yesno

If you develop during your stay with us any of the symptoms listed in the questionnaire above, please contact our Duty Manager or Front Desk for assistance by dialing 1

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Acknowledgement
I acknowledge and agree to the collection, use and disclosure of my personal data, health information and recent travel history for the purposes set out in this form.

I hereby confirm that the above information is accurate to the best of my knowledge:

I Agree

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