Quarantine Station,

Ministry of Health, Labour and Welfare, Government of Japan

Surat Keterangan Pemeriksaan COVID-19

Certificate of Testing for COVID-19

Tanggal penerbitan
Date of issue July 31st, 2022

Nama No. Paspor

Name Kazunori Hayashi, Passport No. TT200253,
Warga Negara Tgl. Lahir Jenis Kelamin
Nationality Japan, Date of Birth April 24th, 1973, Sex Male

Dengan ini diterangkan bahwa telah dilakukan pemeriksaan COVID-19 terhadap orang
tersebut di atas, dan berikut ini adalah hasil dari pemeriksaan tersebut.
This is to certify the following results which have been confirmed by testing for COVID-19
conducted with the sample taken from the above-mentioned person.
Sampel Metode tes COVID-19 Hasil ① Tanggal keluar Catatan
Sample Testing Method for COVID-19 Result hasil Remarks
(Ceklis salah satu kotak di （Ceklis salah satu kotak di bawah ini/Check one of the Test Result Date
bawah ini/Check one of the boxes below） ② Tanggal & jam
boxes below) pengambilan
sampel
Specimen Collection
Date and Time
□ Swab Nasofaring ☑Tes Amplifikasi Asam Nukleat (Metode RT- ☑Negatif ① Lab No:
Nasopharyngeal Swab PCR) Negative Date(yyyy/mm/dd) C.910.22.6582
Nucleic acid amplification test (RT-PCR) 2022/07/31
□Positif Time AM/PM 15:10
□ Air Liur Saliva □Tes Amplifikasi Asam Nukleat (Metode Positive→
LAMP) Tolak Masuk ②
Nucleic acid amplification test (LAMP) Jepang Date(yyyy/mm/dd)
No Entry 2022/07/31
☑Swab Nasofaring dan □Tes Amplifikasi Asam Nukleat (Metode TMA) into Japan
Orofaring Nucleic acid amplification test (TMA) Time AM/PM 10:50
Nasopharyngeal and
oropharyngeal swabs □Tes Amplifikasi Asam Nukleat (Metode TRC)
Nucleic acid amplification test (TRC）

□Tes Amplifikasi Asam Nukleat（Metode

Smart Amp)
Nucleic acid amplification test (Smart Amp）

□Tes Amplifikasi Asam Nukleat (Metode

NEAR)
Nucleic acid amplification test (NEAR）

□Sekuensing Generasi Berikutnya

Next generation sequence

□Tes Antigen Kuantitatif*

Quantitative antigen test* (CLEIA/ECLEIA)
* Bukan tes antigen kualitatif. / Not a qualitative antigen test.

Nama Institusi Medis Name of Medical institution RSUD Kota PRABUMULIH

Alamat Address of the institution Jl. Lingkar Kel. Gunung Ibul Barat
Kota Prabumulih-South Sumatra (Indonesia)
Tanda tangan dokter Signature by doctor dr. Meida Rarasta
SIP.503.VI.001/048/DPMPTSP/2021