COVID-19 RISK FORM 2021

1

Name* This field is required.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Fill in the 6 questions with YES or NO.

If YES, fill in the answer column with numbers 1 or 5.

If NO, fill with number 0.

4

In the past 14 days,
have you experienced any of the following:

5

Have you ever been outside the house or to a public place?* This field is required.Public places: Markets, health care facilities, crowds of people, and others.

1 = Yes / 0 = No

6

Have you ever used public transportation?* This field is required.

1 = Yes / 0 = No

7

Have you ever traveled outside the city, or international travel or traveled to an area affected by COVID-19 (Red Zone / Black Zone)?* This field is required.

1 = Yes / 0 = No

8

Do you take part in activities that involve other people?* This field is required.

1 = Yes / 0 = No

9

Do you have a history of close contact with anyone who has ODP, PDP or confirmed COVID-19?* This field is required.Close contact: Shaking hands, talking, being in one room / one house.

5 = Yes / 0 = No

10

Do you have fever, cough, runny nose, sore throat and / or shortness of breath?* This field is required.

5 = Yes / 0 = No

11

YOUR SCORE

12

YOUR SCORE = 0

13

YOUR SCORE = 1 - 4

14

YOUR SCORE > 5

15

SORRY, you cannot do Raja Ampat Online Registration.

High Risk (Resiko Besar) is not allowed to enter Raja Ampat Regency. We recommend that you consult a health worker.

16

Thank you for conducting an Honest Covid-19 Risk Self-Assessment.
Make sure your body is in a healthy condition with a body temperature of

Please continue to Online Registration.

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