KEMENTERIAN KESEHATAN BADAN PENGEMBANGAN DAN PEMBERDAYAAN SUMBERDAYA MANUSIA KESEHATAN

JI. Hang Jebat III / Blok F3 Kebayoran Baru PO. Box. No. 6015/JKS GN Jakarta 12120 Telp. : (021) 7245517 - 7279 7302 Fax. (021) 7258139 - 725 8057
Nomor Lampiran Hal

D'M·.Ol· 03/r 11[. S/068fJb/10II

: l(satu) berkas : Pra Penetapan Peserta Tugas Belajar Program D-IV, 5-1,5-2 dan S-3 Dalam Negeri Tahun 2011

6 Oktober

2011

Yang terhormat, 1. 2. 3. 4. 5. 6. 7. 8. 9. Inspektur Jenderal Kemenkes Direktur Jenderal Bina Upaya Kesehatan Kemenkes Direktur Jenderal Bina Gizi dan Kesehatan Ibu dan Anak Kemenkes Direktur Jenderal P2&PL Kemenkes Direktur Jenderal Bina Kefarmasian dan Alkes Kemenkes Kepala Badan Litbangkes Kemenkes Kepala Biro Kepegawaian Setjen Kemenkes Sekretaris Badan PPSDM Kesehatan Kemenkes Kepala Dinas Kesehatan Provinsi seluruh Indonesia Surat Edaran Sekretaris Jenderal Kementerian Kesehatan No. DM.01.03/H.II/0393/2011 tanggal 20 Juni 2011 perihal Calon Peserta Tugas Belajar SDM lainnya terkait pelaksanaan

Menindaklanjuti

tanggal 21 Maret 2011 perihal Surat Edaran Bantuan Beasiswa Tubel SDM Kesehatan TA 2011, serta Surat kami No.DM.01.03/V.3j2125 penerimaan Kesehatan yang ikut Seleksi Akademik tahun 2011, serta informasi-informasi kami sampaikan beberapa hal, sebagai berikut : 1. Daftar nama calon peserta tugas belajar program D-IV, S-l, S-2 dan $-3 Dalam Negeri Tahun 2011, merupakan pertemuan maupun 2. pra penetapan peserta tugas belajar SDM Kesehatan tahun 2011 berdasarkan hasil pra penetapan yang telah dilaksanakan pada tanggal5 sd 7 September 2011 di Bandung Kesehatan

calon peserta tugas belajar SDM Kesehatan Dalam Negeri tahun 2011, bersama ini kami

yang diikuti pengelola tugas belajar SDM Kesehatan baik dari Unit Pusat Kementerian Dinas Kesehatan Provinsi.

Bagi Dinas Kesehatan Provinsi yang ikut pada pertemuan

tersebut pada butir 1), data dan informasi

lulus dan registrasi ulang berdasarkan surat maupun informasi dari calon peserta. 3. Nama-nama mendapatkan sumber dana sesuai dari butir 1) adalah calon pesrta tugas belajar dan SDM Kesehatan yang akan SDM

bantuan beasiswa tugas belajar SDM Kesehatan mulai tahun anggaran 2011 dengan DIPA Pusat Standardisasi, Sertifikasi Pendidikan Berkelanjutan

Kesehatan TA 2011. 4. Dalam rangka percepatan direncanakan akan menerima penetapan bagi calon peserta tugas belajar SDM Kesehatan yang

bantuan beasiswa tugas belajar dengan sumber dana Dekonsentrasi calon peserta tugas belajar SDM Kesehatan yang telah pendidikan, serta direncanakan akan

di Dinas Kesehatan Provinsi dan dana bantuan beasiswa tugas belajar di Poltekkes Kemenkes TA 2011, kami harapkan memenuhi menerima agar nama-nama syarat administrasi, dan saat ini telah mengikuti

bantuan beasiswa TA 2011, agar segera disampaikan untuk proses lebih lanjut.

KEMENTERIAN KESEHATAN BADAN PENGEMBANGAN DAN PEMBERDAYAAN SUMBERDAYA MANUSIA KESEHATAN

JI. Hang Jebat III / Blok F.3 Kebayoran Baru

ro Box.

No. 6015/JKS GN Jakarta

12120

Telp. : (021) 7245517 - 7279 7302 Fax. (021) 7258139 - 7258057

5.

Khusus untuk calon peserta sesuai butir 11, agar melengkapi dokumen sebagai berikut: a. b. c. d. e. Bukti registrasi Biodata peserta tugas belajar (terlampir) Fotocopy Kartu Tanda Mahasiswa Surat Pernyataan Surat Pernyataan Bersedia menanggung dari Bendahara Biaya Tugas Belajar, di luar komponen yang menyatakan Peserta Tugas yang dibiayai Belajar yang dari DIPA Pustanserdik SDM Kesehatan Badan PPSDM Kesehatan Gaji bersangkutan f. g. h. i. tidak menerima tunjangan Struktural atau Fungsional dan telah bebas tugas

(bagi peserta tugas belajar regula r) Surat Pernyataan Tidak Sedang Menduduki Khusus peserta yang diusulkan Bukti tiket transport dan 5PPD (contoh Dokumen butir Jabatan (terlampir) Surat Izin Tugas yang dituju studi Dinas Kesehatan Provinsi, agar melengkapi asal ke tempat institusi

Belajar dari Pembina Kepegawaian Daerah (Provinsi/kabupaten/Kota) kedatangan dari tempat pendidikan terlampir), khusus bagi peserta tugas belajar regular. masing-masing peserta sesuai jenjang

a) sid h), agar di kelompokan

pendidikan dalam map, yaitu D-IV (hijau), 5-1 (blru), 5-2 (kuning) dan 5-3 (merah). 6. Dokumen sesuai butir 4) dan 5), selambat-Iambatnya ala mat : Kepala Bidang Pendidikan Pusat Standardisasi, Berkelanjutan SDM Kesehatan Berkelanjutan SDM Kesehatan sudah diterima tanggal 14 Oktober 2011, ke

Sertifikasi

dan Pendidikan

Gedung Badan PPSDM Kesehatan (lantai 4) Jalan Hang Jebat III/F.1I1 Kebayoran baru Jakarta Selatan 12120 7. Jika kelengkapan yang bersangkutan dokumen sebagaimana tidak pada butir 5), tidak dipenuhi persyaratan oleh calon peserta, maka

dianggap

memenuhi

sebagai peserta Tugas Belajar SDM

Kesehatan Tahun 2011, dengan sumber dana DIPA Pustanserdik TA 2011, dan tidak akan diproses lebih lanjut dalam penetapan sebagai peserta tugas belajar tahun 2011. Atas perhatian dan kerjasama Saudara, kami ucapkan terima kasih.

Kesehatan

Tembusan Yth. Menteri Kesehatan RI, sebagai laporan

BIODATA PE5ERTA TUGA5 BELAJAR D-IV, 5-1, 5-2 DAN 5-3 DALAM NEGERI TAHUN 2011

1. PROVINSII

UNIT UTAMAA5AL

2. NAMA LENGKAP 3. TEMPATITGL LAHIR

4. JENI5 KELAMIN 5. ALAMAT SESUAI KTP

5. ALAMAT SEKARANG 6. NO. TELP I HP 7. NIP 8. PANGKAT/GOLONGAN 9. UNIT KERJA 10. NAMA ATASAN LANGSUNG 11. NO. HP. ATASAN LANG5UNG 12. UNIVERSITAS YANG DITUJU 13. FAKUL TAS 14. PROGRAM STUDI 13. PEMINATAN 14. KELAS *) 15. NPM (NOMOR POKOK MAHASISWA) 16. SEMESTER Keterangan: *) Coret salah satu. Tanda tangan, nama jelas ybs,
Pas Fata
3x4

: REGUlER :

I NON REGUlER

SURATPERNYATAAN
Yang bertandatangan Nama Tempat & tanggallahir Pangkat / Gol Unit Kerja Provinsi / Unit Utama Asal Alamat di bawah ini,

Dengan ini menyatakan pada Universitas dibayarkan Demikian

bahwa saya bersedia

Menanggung

Biaya Pendidikan

Tugas Belajar Biaya yang

di Luar Komponen

dari DIPA Pustanserdik surat pernyataan

SDM Kesehatan Badan PPSDM Kesehatan Kemenkes, buat dengan sesungguhnya dan saya bersedia

ini saya

mempertanggung

jawabkan dikemudian

hari apabila pernyataan

saya tidak benar .

.................., Yang Menyatakan

2011

MATERA] 6000

NIP

..

SURAT PERNYATAAN
(8agi Peserta Kelas Reguler)

NAMA NIP UNIT KERJA SAAT INI SEDANG MENGIKUTI REGULER 01 UNIVERSITAS PROGRAM STUDI MULAI TAHUN AKADEMIK PROGRAM PENDIDIKAN '" PEMINATAN SEMESTER .. D-IV I S-1 I S-2 I S-3 *) KELAS .. .

MENYATAKAN BAHWA, SAAT INI SAYA SEDANG MENGIKUTI PENOIOIKAN DAN TIDAK SEOANG MENDUOUKI JABATAN STRUKTURALIFUNGSIONAL *) 01 UNIT KERJA OIMANA SAYA BEKERJA SAAT INI SELAKU PNS. DEMIKIAN SURA T PERNYA TAANINI SA YA BUAT DENGAN BENAR, DAN APABILA PERNYATAAN SA YA INI TIDAK BENAR, MAKA SA YA BERSEOIA DITUNTUT SESUAI DENGAN PERATURAN YANG BERLAKU.

YANG MEMBUAT PENYATAAN,

METERAf Rp. 6000,-

MENGETAHUI: ATASAN LANGSUNG

Nama Jelas

KET: 1. *) Pilih salah satu. 2. - Kelas Reguler adalah peserta mengikuti tugas belajar dan sepenuhnya meninggalkan tug as pokoknya. - Kalas Non Reguler adalah peserta mengikuti tugas belajar tanpa meninggalkan tugas jabatannya, mengikuti tugas belajar di luar jam kedinasan, dan tidak sepenuhnya meninggalkan tugas pokoknya.

Berangkat dari [tempat kedudukan Pada tanggal Ke

Tempat Tujuan

1
Tanggal sampai

Jabatan pe:nahtfatcln!iJan dari pihak ·unitkerja asal

tandatangan

NIP.

I. Tiba di Pada tanggal Kepala

Tempal perkulrahan Tempat Tujuan l'ang.galberangkat Jabatan penandatangan dari piflak univ/Poltek
tandatangal1

Berangkat dari Ke Pada tanggal Kepala

NIP. II. Tiba di Pada tangga! Kepala Berangkat dari Ke Pada tanggal Kepala

III. Tiba di Pada tanggal Kepala

Berangkat dari Ke Pada langgal Kepala

NIP

NIP

IV. Tiba kembali Pada tanggal

di :

Telah diperiksa dengan keterangan bahwa perjalanan tersebut diatas

[tempat kedudukan

benar dilakukan atas perintahnya dan semata-mata untuk kepentingan jabatan dalam waktu yang sesingkat-singkatnya. An. Kuasa Pengguna Anggaran Pusat Pemberdayaan Profesi dan Tenaga Kesehatan Luar Negeri Depkes RI Pejabat Pembuat Komilmen

Ir. Purwadi Ardinoto, M.Kes. NIP196009081984021 V. Catatan lain-lain: VI. PERHATIAN: Pejabat yang berwenang menerbitkan SPPD pegawai melakukan Perjalanan Dinas, Para Pejabat yang mengesahkan tanggal berangkatltiba serta Bendaharawan berlanggung jawab/berdasarkan peraturan Keuangan Negara apabila negara menderita ru i akibat kesalahan, kelalaian, keal aan an ka 8, No. 296/MKlII4/1974
.

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