FORM USULAN BARANG BAHAN KIMIA GIGI, REAGEN LAB, DAN REAGEN HIV

POLI/RUANG .
A. BAHAN KIMIA GIGI
NO

NAMA BARANG

1
2

Absorbent
Amalgam Alloy Powder

Amalgam Capsule

Calcium Hidroxyde Pasta

Chlor Ethyl Spray

Composite Resin Light Curing

Cresophene (Rockless)

Devitalisasi Paste Non Arsen

10

Elite Cement Liquid

11

Endomethasone

12
13

Eugenol
Fletcher Powder

14
15
16
17
18
19
20
21
22
23
24

MEREK
SDI Australia
SDI Tipe F400
1 spill
Doridont
Austria
Walter Ritter
Tokuyama
Japan
Septodont
France
Septodont
France
GC
Septodont
France
Ghimas Italy
Apotik Roxi

Glass Ionomer Cement GC Gold

Label Fuji IX A3
Glass Ionomer Cement GC Gold
Label Fuji IX A3,5

Guttap Percha Points

Guttap Percha Points

SPESIFIKASI
Threatment No. 25,30
F 400 Powder/botol 30 gr
Capsule isi 5 x 10/box
2 set/box, Base 13 gr, Catalyst 11 gr

Kemasan Kaleng 100mL

Set (1 bot Etching, 1 bot Bonding dan 6 syringe)
13 mL botol/solution
botol 4,5 gr

100 gr
7 gr Botol Powder
10 mL botol/solution
Topples Plastik kecil
Fuji IX A3, 5 gram
Fuji IX A3,5 , 15 gram
No. 15/80 kotak

Inline

Pegisian Saluran Akar, Uk 40 & 50

Guttap protaper

Box isi 60

Hg (Air Raksa)

Botol 100 gr

Larutan Antiseptik Root

Canal/CHKM
Matrik + Holder

Oil Spray

botol/10 ml
Stainless Steel

NSK Japan

Oil Spray

Handpiece Lubricant, 480 mL

kaleng, pelumas handpiece, 170 ml
uk 15 dan 20, 15 - 40

Paper Points

25

Paper Points

Inline

Pengering Saluran Akar/Endodontic, Uk 25 & 30

26
27
28

Pasta Mumifikasi
Pehacain

Kalbe Farma

Lidocain HCl Box isi 20 amp

Protaper 25 mm (hand)

29

Pulperil

30

Scandonest 3%

31
32
32

Spongostan
Temporary Filling Pasta
Zn PO4 (Zinc Phospat) cement

33

Zn PO4 (Zinc Phospat) cement

kotak isi 6

Septodont
France
Septodont
France
Curaspon
Cavit G
GC

13 mL botol/solution
Adrenalin 18 mcg, Meficain 36 mg, 50
ampul/box
Cube 1x1x1 xm, steril, 50 cube/ box
Pot Glass 28 gr Paste
Pot ( Powder 125 gr,)

Doridont
Austria

Multifix, powder 30 gr Liquid 10 mL

B. REAGEN LABORATORIUM
NO

NAMA BARANG

MEREK

Bilirubin Direk
Bilirubin Total
Bilirubin Total Liquid

BTA Reagen - Asam Alkohol 3% StReagen

100 mL

BTA Reagen - Carbol Fuchsin 1%

StReagen

100 mL

StReagen

100 mL

Aim

(1:2:1) 4 x Botol 100 mL

Human
Human

CHOD PAP mono, 4 x 30 mL

6
7
8
9

BTA Reagen - Metylen Blue

0,1%
BTA Ziehl Nelson
Cholesterol Total Liquid
Control Serum/Kimia Darah

Reflotron
Reflotron
Human

SPESIFIKASI

1
2
3

30 strip/tube
30 strip/tube
2 x 100 mL

6 x 5 mL

10
11

Creatinine
Creatinine Liquid

Reflotron

12

Cuvettest Hb

HemoCue

13

Eter Alkohol

IndoReagen

14

Golongan Darah

Proven/RPA

15
16
17
18
19

HbsAb (Anti Hbs)

HBsAg
HDL Cholesterol

SD
SD
Human
IndoReagen

20

Lipid Panel

21

Multi Panel Urine Drug Test

22
23

Natrium Citrat 3.8 %

Olium Emersi/Olie Immersion

24
25

KOH 10%
Laboratory Detergent

Human

Extran
Cardio Chec/
PTS Panels

30 strip/tube
1 x 200 mL
Hb 301 Microcuvettes (4x50 pcs) vials
Untuk Alat Hb Fotometri

500 mL
Reagen anti A, anti B, anti AB, anti D / Rhesus 10
ml
Anti HBs Test, 30 test/tube
Hepatitis B Surface Antigen, 30 test/tube
4 x 80 mL
100 mL

500 mL
15 strip/tube, Total Chol., HDL, Trig., calc. LDL)
4 parameter (benzo,opiat,THC,amfetamin) box
isi 25 pcs

IndoReagen
IndoReagen

Reagensia Hematologi Human

Cleaner M
Reagensia Hematologi - Diluent
Human
M

100 mL
500 mL

1 L, HC Cleaner, Humacon 30 TS
20 L, HC Diluent

26

Reagensia Hematologi - M-Lyse Human

1 L, HC Lyse CF, Humacon 30 TS

27

Reagensia Hematology - Control

Hematology

Human

HC Control, Humacon 30 TS, Low, High, Normal

SGOT

Reflotron

SGOT Liquid

Human

SGPT

Reflotron

SGPT Liquid
Spiritus Bakar/Putih

Human
Lokal

30
10
30
10
20

Strip Gula Darah

Strip Hb

Major II
Mission

isi 50 strip/tube

Strip Kolesterol Total

Strip Uric Acid

Family Dr.
Family Dr.

10 strip/tube
25 strip/tube

Tes Kehamilan (HCG strip)

Oncoprobe

25 stik/box

Triglyseride Liquid

Human

Ureum
Ureum Liquid

Reflotron
Human

Uric Acid Liquid

Urine Analysis 3 Tube
Urine Tes 10 Parameter

Human

9 x 15 mL
15 strip/tube
2 x 100 mL
4 x botol 30 mL
Isi 50 Strip (Proteiin, PH, Glukosa)
50 strip/box

Widal Test

Proven/RPA

28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

strip/tube
x 10 mL
strip/tube
x 10 mL
L

8 Vial

C. REAGEN HIV
NO

NAMA BARANG

1
2
3
4

Anti HCV
Rapid Test Syohilis
Metylen Blue 0,3%
Pewarna Giemsa

Reagen HIV Rapid ke-3

6
7

Reagen HIV Rapid ke-1

Reagen HIV Rapid ke-2

NO

USULAN TAMBAHAN

MEREK
BioFarma
Hexagon
StReagen

SPESIFIKASI
50 Stik/Box
20 strip/box
100 mL
100 mL

Human/Hexago
Human 1 & 2 isi 40
n
Triline/intec
isi 100 test
SD Bioline
isi 100

MEREK

SPESIFIKASI

GEN LAB, DAN REAGEN HIV 2016

GI
HARGA / Satuan (Tahun
2015)

IDR

1,400,000

IDR

480,000

IDR

95,000

IDR

3,750,000

IDR

604,500

IDR

250,000

IDR

403,535

IDR

515,000

IDR
IDR

21,667
25,000

IDR

319,000

IDR

790,000

IDR
IDR
IDR
IDR

66,000
66,000
85,000
300,000

IDR

70,000

IDR
IDR
IDR
IDR

235,000
450,000
60,000

IDR

IDR
IDR
IDR

214,500
71,469
85,000

IDR

404,800

IDR

513,500

IDR
IDR
IDR

493,350
115,000
350,000

IDR

222,453

TOTAL
USULAN

SATUAN

Tube

Botol

Botol

Botol
Box

Box

RIUM
HARGA / Satuan (Tahun
2015)

IDR
IDR
IDR

652,740
652,740
838,063

TOTAL
USULAN

SATUAN
Tube
Tube
Kit
Botol
Botol
Botol

IDR
IDR

242,000
1,087,900

Kit

IDR

1,196,250

Kit

Kit

Tube

IDR
IDR

694,485
800,000

IDR

14,231

IDR

161,700

Botol

IDR

494,000

Set

IDR
IDR

924,000
792,000

IDR

1,406,900

Kit
Test

IDR

35,000

Tube
Tube
Set
Botol

IDR

747,500

Botol

USD

124.89

Tube

IDR

79,200

Strip

IDR
IDR

96,250
465,850

Botol
Botol

IDR

722,189

Botol

IDR

2,713,425

Jerigen

IDR

1,885,483

Botol

IDR

6,181,043

Kit

IDR

652,740

IDR

710,000

IDR

652,740

Tube

IDR
IDR

710,000
445,500

IDR

9,410

IDR
IDR

330,000
253,000

Kit
Galon
Strip
Tube
Tube
Tube

IDR

331,350

IDR

2,012,500

IDR
IDR

326,370
695,750

IDR
IDR
IDR
IDR

1,140,000
179,000
220,000
1,265,000

HARGA / Satuan (Tahun

2015)

Tube
Kit

Box
Kit

Tube
Kit
Kit
Kit
Box

Set

TOTAL
USULAN

SATUAN

IDR
IDR
IDR

3,110,640
1,188,560
113,750

IDR

509,450

Kit
Box
Botol
Botol

IDR

42,000

Test

IDR
IDR

42,000
42,000

Test
Test

HARGA / Satuan

TOTAL
USULAN

SATUAN

Penanggung Jawab

(..)
NIP: ..

FORM USULAN BARANG BAHAN KIMIA GIGI, REAGEN LAB, DAN REAGEN HIV
PUSKESMAS KELURAHAN .
A. BAHAN KIMIA GIGI
NO

NAMA BARANG

1
2

Absorbent
Amalgam Alloy Powder

Amalgam Capsule

Calcium Hidroxyde Pasta

Chlor Ethyl Spray

Composite Resin Light Curing

Cresophene (Rockless)

Devitalisasi Paste Non Arsen

10

Elite Cement Liquid

11

Endomethasone

12
13

Eugenol
Fletcher Powder

14
15
16
17
18
19
20
21
22
23
24

MEREK
SDI Australia
SDI Tipe F400
1 spill
Doridont
Austria
Walter Ritter
Tokuyama
Japan
Septodont
France
Septodont
France
GC
Septodont
France
Ghimas Italy
Apotik Roxi

Glass Ionomer Cement GC Gold

Label Fuji IX A3
Glass Ionomer Cement GC Gold
Label Fuji IX A3,5

Guttap Percha Points

Guttap Percha Points

SPESIFIKASI
Threatment No. 25,30
F 400 Powder/botol 30 gr
Capsule isi 5 x 10/box
2 set/box, Base 13 gr, Catalyst 11 gr

Kemasan Kaleng 100mL

Set (1 bot Etching, 1 bot Bonding dan 6 syringe)
13 mL botol/solution
botol 4,5 gr

100 gr
7 gr Botol Powder
10 mL botol/solution
Topples Plastik kecil
Fuji IX A3, 5 gram
Fuji IX A3,5 , 15 gram
No. 15/80 kotak

Inline

Pegisian Saluran Akar, Uk 40 & 50

Guttap protaper

Box isi 60

Hg (Air Raksa)

Botol 100 gr

Larutan Antiseptik Root

Canal/CHKM
Matrik + Holder

Oil Spray

botol/10 ml
Stainless Steel

NSK Japan

Oil Spray

Handpiece Lubricant, 480 mL

kaleng, pelumas handpiece, 170 ml
uk 15 dan 20, 15 - 40

Paper Points

25

Paper Points

Inline

Pengering Saluran Akar/Endodontic, Uk 25 & 30

26
27
28

Pasta Mumifikasi
Pehacain

Kalbe Farma

Lidocain HCl Box isi 20 amp

Protaper 25 mm (hand)

29

Pulperil

30

Scandonest 3%

31
32
32

Spongostan
Temporary Filling Pasta
Zn PO4 (Zinc Phospat) cement

33

Zn PO4 (Zinc Phospat) cement

kotak isi 6

Septodont
France
Septodont
France
Curaspon
Cavit G
GC

13 mL botol/solution
Adrenalin 18 mcg, Meficain 36 mg, 50
ampul/box
Cube 1x1x1 xm, steril, 50 cube/ box
Pot Glass 28 gr Paste
Pot ( Powder 125 gr,)

Doridont
Austria

Multifix, powder 30 gr Liquid 10 mL

B. REAGEN LABORATORIUM
NO

NAMA BARANG

MEREK

Bilirubin Direk
Bilirubin Total
Bilirubin Total Liquid

BTA Reagen - Asam Alkohol 3% StReagen

100 mL

BTA Reagen - Carbol Fuchsin 1%

StReagen

100 mL

StReagen

100 mL

Aim

(1:2:1) 4 x Botol 100 mL

Human
Human

CHOD PAP mono, 4 x 30 mL

6
7
8
9

BTA Reagen - Metylen Blue

0,1%
BTA Ziehl Nelson
Cholesterol Total Liquid
Control Serum/Kimia Darah

Reflotron
Reflotron
Human

SPESIFIKASI

1
2
3

30 strip/tube
30 strip/tube
2 x 100 mL

6 x 5 mL

10
11

Creatinine
Creatinine Liquid

Reflotron

12

Cuvettest Hb

HemoCue

13

Eter Alkohol

IndoReagen

14

Golongan Darah

Proven/RPA

15
16
17
18
19

HbsAb (Anti Hbs)

HBsAg
HDL Cholesterol

SD
SD
Human
IndoReagen

20

Lipid Panel

21

Multi Panel Urine Drug Test

22
23

Natrium Citrat 3.8 %

Olium Emersi/Olie Immersion

24
25

KOH 10%
Laboratory Detergent

Human

Extran
Cardio Chec/
PTS Panels

30 strip/tube
1 x 200 mL
Hb 301 Microcuvettes (4x50 pcs) vials
Untuk Alat Hb Fotometri

500 mL
Reagen anti A, anti B, anti AB, anti D / Rhesus 10
ml
Anti HBs Test, 30 test/tube
Hepatitis B Surface Antigen, 30 test/tube
4 x 80 mL
100 mL

500 mL
15 strip/tube, Total Chol., HDL, Trig., calc. LDL)
4 parameter (benzo,opiat,THC,amfetamin) box
isi 25 pcs

IndoReagen
IndoReagen

Reagensia Hematologi Human

Cleaner M
Reagensia Hematologi - Diluent
Human
M

100 mL
500 mL

1 L, HC Cleaner, Humacon 30 TS
20 L, HC Diluent

26

Reagensia Hematologi - M-Lyse Human

1 L, HC Lyse CF, Humacon 30 TS

27

Reagensia Hematology - Control

Hematology

Human

HC Control, Humacon 30 TS, Low, High, Normal

SGOT

Reflotron

SGOT Liquid

Human

SGPT

Reflotron

SGPT Liquid
Spiritus Bakar/Putih

Human
Lokal

30
10
30
10
20

Strip Gula Darah

Strip Hb

Major II
Mission

isi 50 strip/tube

Strip Kolesterol Total

Strip Uric Acid

Family Dr.
Family Dr.

10 strip/tube
25 strip/tube

Tes Kehamilan (HCG strip)

Oncoprobe

25 stik/box

Triglyseride Liquid

Human

Ureum
Ureum Liquid

Reflotron
Human

Uric Acid Liquid

Urine Analysis 3 Tube
Urine Tes 10 Parameter

Human

9 x 15 mL
15 strip/tube
2 x 100 mL
4 x botol 30 mL
Isi 50 Strip (Proteiin, PH, Glukosa)
50 strip/box

Widal Test

Proven/RPA

28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44

strip/tube
x 10 mL
strip/tube
x 10 mL
L

8 Vial

C. REAGEN HIV
NO

NAMA BARANG

1
2
3
4

Anti HCV
Rapid Test Syohilis
Metylen Blue 0,3%
Pewarna Giemsa

Reagen HIV Rapid ke-3

6
7

Reagen HIV Rapid ke-1

Reagen HIV Rapid ke-2

NO

USULAN TAMBAHAN

MEREK
BioFarma
Hexagon
StReagen

SPESIFIKASI
50 Stik/Box
20 strip/box
100 mL
100 mL

Human/Hexago
Human 1 & 2 isi 40
n
Triline/intec
isi 100 test
SD Bioline
isi 100

MEREK

SPESIFIKASI

GEN LAB, DAN REAGEN HIV 2016

HAN .

GI
HARGA / Satuan (Tahun
2015)

IDR

1,400,000

IDR

480,000

IDR

95,000

IDR

3,750,000

IDR

604,500

IDR

250,000

IDR

403,535

IDR

515,000

IDR
IDR

21,667
25,000

IDR

319,000

IDR

790,000

IDR
IDR
IDR
IDR

66,000
66,000
85,000
300,000

IDR

70,000

IDR
IDR
IDR
IDR

235,000
450,000
60,000

IDR

IDR
IDR
IDR

214,500
71,469
85,000

IDR

404,800

IDR

513,500

IDR
IDR
IDR

493,350
115,000
350,000

IDR

222,453

TOTAL
USULAN

SATUAN

Tube

Botol

Botol

Botol
Box

Box

RIUM
HARGA / Satuan (Tahun
2015)

IDR
IDR
IDR

652,740
652,740
838,063

TOTAL
USULAN

SATUAN
Tube
Tube
Kit
Botol
Botol
Botol

IDR
IDR

242,000
1,087,900

Kit

IDR

1,196,250

Kit

Kit

Tube

IDR
IDR

694,485
800,000

IDR

14,231

IDR

161,700

Botol

IDR

494,000

Set

IDR
IDR

924,000
792,000

IDR

1,406,900

Kit
Test

IDR

35,000

Tube
Tube
Set
Botol

IDR

747,500

Botol

USD

124.89

Tube

IDR

79,200

Strip

IDR
IDR

96,250
465,850

Botol
Botol

IDR

722,189

Botol

IDR

2,713,425

Jerigen

IDR

1,885,483

Botol

IDR

6,181,043

Kit

IDR

652,740

IDR

710,000

IDR

652,740

Tube

IDR
IDR

710,000
445,500

IDR

9,410

IDR
IDR

330,000
253,000

Kit
Galon
Strip
Tube
Tube
Tube

IDR

331,350

IDR

2,012,500

IDR
IDR

326,370
695,750

IDR
IDR
IDR
IDR

1,140,000
179,000
220,000
1,265,000

HARGA / Satuan (Tahun

2015)

Tube
Kit

Box
Kit

Tube
Kit
Kit
Kit
Box

Set

TOTAL
USULAN

SATUAN

IDR
IDR
IDR

3,110,640
1,188,560
113,750

IDR

509,450

Kit
Box
Botol
Botol

IDR

42,000

Test

IDR
IDR

42,000
42,000

Test
Test

HARGA / Satuan

TOTAL
USULAN

SATUAN

Kepala Puskesmas
Kelurahan

(..)
NIP: ..