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Mulyadi
2020-11-30T09:29:52+00:00
Corona Virus Self-Assessment Form
Booking Number
Arrival Date
Date Format: MM slash DD slash YYYY
Departure Date
Date Format: MM slash DD slash YYYY
Number Of Participant
Name Of Participant and Age
Email (1 of participant)
Phone Number (1 of participant)
Nationality
In last 14 days, have you ever experienced the following?
1. Have you or one of your participant even been out of your house/public place (Market, Public Crowd etc.)?
YES
NO
2. Have you or one of your participant ever used public transportation?
YES
NO
3. Have you or one of your participant ever been to one the COVID-19 affected countries?
YES
NO
3. Have you or one of your participant ever participated in activity that involved a lot of people?
YES
NO
4. Have you or one of your participant been in closed contact with a confirmed case of coronavirus?
YES
NO
5. Are you or one of your participant currently experiencing symptoms (fever, cough, cold, sore throat, shortness of breath)?
YES
NO
By submitting I hereby confirm that the information I have given above is true, and that I will comply with the terms and conditions outlined above. Further Action: If you or one of the member of the group having Body Temperature > 37.3’C or experiencing the corona symptoms as mentioned in the question no. 5, please contact our customer care member through phone no: +62 813-3707-1135 (available in whats app, sms or phone call) or through our email : client.indonesia@happytrailsasia.com
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