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FORMULIR PEMANTAUAN COVID-19
Dinas Kesehatan Kabupaten Kotabaru
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NIK
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Nama Lengkap
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Tanggal Lahir
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DD
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YYYY
Jenis Kelamin
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Laki-laki
Perempuan
Nomor HP
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Alamat Lengkap
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Kecamatan
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Kelurahan
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E-mail (jika ada)
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Keluhan
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Demam (>38˚C)
Batuk
Pilek/Flu
Sakit Tenggorokan
Sesak Nafas
Lemas
TIdak Ada Keluhan
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Jumlah Anggota Keluarga
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RIWAYAT BEPERGIAN KE LUAR DAERAH:
Kota/Daerah Tujuan
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Tanggal Berangkat
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DD
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Tanggal Tiba
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MM
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