Declaration Form Dear Guest, Due to the recent outbreak of the Corona viruses and in line with the Government of Indonesia’s directives to mitigate the spread of Corona viruses, and having regard for your health and safety and that of the other guests, we would request for your cooperation in taking precautionary measures to prevent the spread of the new coronavirus-related pneumonia. If you could kindly fill out this declaration it would be most appreciated. In providing the below information, you consent to our collection, use, processing, transfer, and/or disclosure of your personal data in accordance with all applicable laws for the purposes of monitoring, evaluating, and responding to the novel coronavirus (2019-nCoV) outbreak. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Do you have fever, a dry cough, breathing difficulties, severe muscle aches, Continuous chest pains or chills and shivering? “if you answer is “Yes”, we suggest to arrange immediate medical attention for you yes no Have you had any contact with a new coronavirus-related pneumonia patient in the past 14 days? yes no Have any one of your immediate family members had contact with a new corona virus-related pneumonia patient in the past 14 days? yes no Have you visited (country in pandemic) in the past 14 days? yes no Please list all countries you have visited in the last 10 days Please list all cities in world that you have visited in the last 10 days If you answer is “Yes” to any of the question 2-4, may we suggest that you monitor your health for at least 14 days. If you become ill with symptoms listed in item 1, do inform us immediately. Or if you have checked-out of the hotel, we suggest you see a doctor immediately. Name Room No. Nationality Identification/ Passport Mode of Transport (air) Flight: Seat No. Mode of Transport (sea)Vessel name: Mode of Transport (land) Vehicle no: Purpose of visit Thank you for your understanding and co-operation and we apologize for any inconvenience caused. Submit
