Document Number

DOMESTIC TRAVEL & 01 January

Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 1 of 1

Employees who travel domestically when entering the Gorontalo Sejahtera Mining site must fill
out this form. A copy of this document must be sent to GSM site management i.e HR, HSE,
Company Doctor & Site Service at least three (3) days before departure.

Subject Date :
To Human Resources [email protected]

Company Doctor [email protected]

[email protected]
Site Services [email protected]
[email protected]
HSE [email protected]
[email protected]
Cc Head of Mining Engineering [email protected]
[email protected]
Exploration Manager [email protected]
Commercial Manager [email protected]
External Affairs Manager [email protected]

Itinerary
Name
Position
Company
Company Address
Handphone Number
Email
Home Address
Medical Medication
Allergy
Chronic Disease History
Family

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 2 of 1

Trip Details
Objective
PGP
Employee
No. Date Flight No. Destination Destination Departure Destination
Time Time

Accommodation
 Marisa Mess  Baganite Camp  Others: (Hotel) …….

 PBC Camp  Pioneer Camp

Land Transportation
Please contact Accommodation & Transportation Section for any inquiries

Harapan Simamora (Hp): 0813 4083 5722

Budi Siswanto (Hp): 0812 1446 9793
Mohamad Bill Iqbal (Hp):0852 5522 3456

Emergency Equipment
Map (Attached): Yes No

GSM Signal: Yes No Type:

Satellite Phone: Yes No

First Aid Kit: Yes No

GPS: Yes No

APD & Extra protection:

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 3 of 1

Emergency Situation
Incase of an emergency situation, kindly please notify the following emergency contacts immediately:
1. Head of Mining Engineer Gorontalo Sejahtera Mining:

PT GSM
Widji Pramadjati (Hp) : 0812 1080 3467
2. Exploration
Eddy Da Costa (Hp) : 0813 4027 7445
3. External Affair
Mahesha Lugiana (Hp) : 0821 49494 5736
4. Commercial
Heber Manurung (Hp) : 081 1109 4803
5. Human Resources
Adi Firdaus (Hp) : 0811 541 8168
6. Health Safety and Environment
Abdul Rahman (Hp) : 0812 402 9408
Jose Christie (Hp) : 0852 2828 6666
7. Company Doctor
Panji Kesuma Aulia (Hp) : 0812 8712 2129
Jeremia Mone (Hp) : 081 1933 9168
8. PT GSM
Jl. Sumur Bor, Dusun Melati, Desa Marisa Utara, Kecamatan Marisa, Kabupaten Pohuwato, Kode pos 96266,
Provinsi Gorontalo.

Hospital
Gorontalo
RSUD Aloei Saboe
Jalan Prof. Dr. Hi. Aloei Saboe, Wongkaditi, Kota Utara, Kota Gorontalo, Gorontalo 96115
Telepon:  0435 - 821 924

Gorontalo
RSU Bioklinik
Jl. Pangeran Diponegoro No.52, Limba B, Kota Sel., Kota Gorontalo, Gorontalo 96115
Telepon:  0821 5937 1157

Pohuwato
RSUD POHUWATO
JL. Teratai, Botubilotahu  96266  Kab. Pohuwato Provinsi Gorontalo
Telepon:  0443 – 210 880

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 4 of 1

Map

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 5 of 1

Screening Form and Detection Corona Virus (COVID-19)

Personal Data
Name Position
ID No Department
Age (DOB) Body Temperature
Result
Nationality Blood Pressure
Company °C
Put a check mark (√) for the most appropriate answer and fill in another section, if
there are no answer choices
1. Are you currently experiencing the 2. Do you have a history of traveling to
following symptoms? countries, regions, or cities in Indonesia that
were affected by Coronavirus (according to
Yes
the spreading of the disease) in the last 14
No
days? With or without symptoms being
Fever, cough/ common cold present.

Yes X No
Sore throat

Respiratory distress Country/Region/ Date (From-To)

Area
Others _______________________

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 6 of 1

3. Should you be experiencing any symptoms (Question 1), have you had any of the
following exposures in the last 14 days?
Yes No

Any history of contact with COVID-19 confirmed patients

Worked at or visited any healthcare facilities associated with patients

having COVID-19, or

Have you had any contact with persons who have been in a COVID-19-infected area,
in the last 14 days?

Are there any people being monitored, suspected or confirmed COVID-19

within your family, village or sub-district
Note:

If the answer to any of the symptoms in question numbers 1, 2, or 3 is YES you must
report directly to your supervisor and site medic for possible referral to the hospital,
on arrival on site

If you are experiencing the symptom mentioned in question number 1 in the last two days
before traveling back to the site, please contact your supervisor or HR department to get
directions to visit a hospital or medical facility.

4. Vaccination History

Vaccine Type (For example Sinovac, etc) Vaccine Date

Vaccine :
1
Vaccine :
2
Booster :

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING
 Document Number
DOMESTIC TRAVEL & 01 January
Created Date
EMERGENCY 2023

RESPONSE PLAN Revision To 00

Number of Page 7 of 1

Filled by Paramedic Sign by Doctor/Paramedic

Fit to Work
Yes No

Employee/Visitor

Signed

This publication may not be reproduced, stored in the system, or transferred in any form by
any means, electronic, mechanical, photocopying, recorded, or otherwise without the
permission of PT GORONTALO SEJAHTERA MINING