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PEMERINTAH KABUPATEN BERAU Lamp.

Lamp.VI (2 dari 4) Kepmen Keuangan tentang Perjalanan Dinas Dalam Negeri bagi Pejabat Negara Pegawai Negeri Sipil
DINAS KESEHATAN dan Pegawai Tidak Tetap Nomor :7/KMK 02/2003,tanggal 3 Januari 2003
PUSKESMAS SAMBALIUNG I. Berangkat dari tempat kedudukan
Jl.Mangkubumi II RT.07 Sambaliung Pada Tanggal : 27 April 2014
SURAT PERINTAH PERJALANAN DINAS Ke : inaran
1.
2. Nama Pegawai yang diperintahkan
3. a. NIP : #N/A H. Syafrudin. AB
b. Pangkat dan golongan menurut PGPS, 1968 : #N/A NIP. 19590102 198201 1 008
c. Jabatan : #N/A II. Tiba di : inaran Berangkat dari :
d. Tingkat Menurut Peraturan Perjalanan Dinas : Lokal Pada Tanggal : 27 April 2014 Ke :
4. Maksud Perjalanan Dinas : Kegiatan Pely. luar gedung Kepala : Pada Tanggal :
Kepala :

5. Alat angkut yang dipergunakan : Kendaraan Umum


6. a. Tempat berangkat : Puskesmas Sambaliung .......................................
b. Tempat tujuan : inaran
7. a. Lamanya Perjalanan Dinas : 1 ( satu ) Hari III. Tiba di : Berangkat dari :
b. Tanggal berangkat : 27 April 2014 Pada Tanggal : Ke :
c. Tanggal harus kembali : 27 April 2014 Kepala : Pada Tanggal :
8. Pengikut : Nama : Kepala :

9. Pembenaan Anggaran : APBD II IV. Tiba Kembali di Telah diperiksa dengan keterangan bahwa perjalanan
a. Instansi : Dinas Kesehatan Kab. Berau Tersebut diatas benar dilakukan atas perintahnya dan
b. Mata Anggaran : 2014 semata -mata untuk kepentingan jabatan dalam waktu
10 Keterangan lain-lain : sesingkat-singkatnya

Catatan: PEJABAT YANG MEMBERI PERINTAH


1. SPPD ini harus diketahui tanggal tiba dan PADA TANGGAL : 02 Maret 2014 Kepala Puskesmas Sambaliung
berangkat oleh pejabat setempat yang V. Catatan lain-lain
dikunjungi setelah sampai di tempat tujuan Kepala Puskesmas Sambaliung
2. 2 (dua) hari setelah tiba kembali ditempat semula
SPPD harus diserahkan kembali kepada yang H. Syafrudin. AB
memberikan biaya perjalanan NIP. 19590102 198201 1 008 PERHATIAN :
Apabila perintah bepergian diberikan untuk bepergian yang tidak perlu untuk bepergian ongkosnya menurut
peraturan tidak dapat dibayar oleh PEMDA, maka yang memerintahkan Bertanggung jawab atas ongkosnya yang
dikeluarkan (Lihat Artikel No. 74 dari UU.ICW.)

PEMERINTAH KABUPAEN BERAU Lamp.VI (2 dari 4) Kepmen Keuangan tentang Perjalanan Dinas Dalam Negeri bagi Pejabat Negara Pegawai Negeri Sipil
DINAS KESEHATAN dan Pegawai Tidak Tetap Nomor :7/KMK 02/2003,tanggal 3 Januari 2003
PUSKESMAS SAMBALIUNG I. Berangkat dari tempat kedudukan
Jl.Mangkubumi II RT.07 Sambaliung Pada Tanggal : 27 April 2014
SURAT PERINTAH PERJALANAN DINAS Ke : inaran
Nomor : 019/KLG / PKM - SBL / IV / 2014
1. Pejabat yang berwenang memberikan perintah : Kepala Puskesmas Sambaliung
2. Nama Pegawai yang diperintahkan : #N/A
3. a. NIP : #N/A H. Syafrudin. AB
b. Pangkat dan golongan menurut PGPS, 1968 : #N/A NIP. 19590102 198201 1 008
c. Jabatan : #N/A II. Tiba di : inaran Berangkat dari :
d. Tingkat Menurut Peraturan Perjalanan Dinas : Lokal Pada Tanggal : 27 April 2014 Ke :
4. Maksud Perjalanan Dinas : Kegiatan Pely. luar gedung Kepala : Pada Tanggal :
Kepala :

5. Alat angkut yang dipergunakan : Kendaraan Umum


6. a. Tempat berangkat : Puskesmas Sambaliung .......................................
b. Tempat tujuan : inaran
7. a. Lamanya Perjalanan Dinas : 1 ( satu ) Hari III. Tiba di : Berangkat dari :
b. Tanggal berangkat : 27 April 2014 Pada Tanggal : Ke :
c. Tanggal harus kembali : 27 April 2014 Kepala : Pada Tanggal :
8. Pengikut : Nama : Kepala :
9. Pembenaan Anggaran : APBD II IV. Tiba Kembali di : Telah diperiksa dengan keterangan bahwa perjalanan
a. Instansi : Dinas Kesehatan Kab. Berau Tersebut diatas benar dilakukan atas perintahnya dan
b. Mata Anggaran : 2014 semata -mata untuk kepentingan jabatan dalam waktu
10 Keterangan lain-lain : sesingkat-singkatnya

Catatan: PEJABAT YANG MEMBERI PERINTAH


1. SPPD ini harus diketahui tanggal tiba dan PADA TANGGAL : 02 Maret 2014 Kepala Puskesmas Sambaliung
berangkat oleh pejabat setempat yang Kepala Puskesmas Sambaliung V. Catatan lain-lain
dikunjungi setelah sampai di tempat tujuan
2. 2 (dua) hari setelah tiba kembali ditempat semula H. Syafrudin. AB
SPPD harus diserahkan kembali kepada yang H. Syafrudin. AB NIP. 19590102 198201 1 008
memberikan biaya perjalanan NIP. 19590102 198201 1 008 PERHATIAN :
Apabila perintah bepergian diberikan untuk bepergian yang tidak perlu untuk bepergian ongkosnya menurut
peraturan tidak dapat dibayar oleh PEMDA, maka yang memerintahkan Bertanggung jawab atas ongkosnya yang
dikeluarkan (Lihat Artikel No. 74 dari UU.ICW.)

PEMERINTAH KABUPAEN BERAU Lamp.VI (2 dari 4) Kepmen Keuangan tentang Perjalanan Dinas Dalam Negeri bagi Pejabat Negara Pegawai Negeri Sipil
DINAS KESEHATAN dan Pegawai Tidak Tetap Nomor :7/KMK 02/2003,tanggal 3 Januari 2003
PUSKESMAS SAMBALIUNG I. Berangkat dari tempat kedudukan
Jl.Mangkubumi II RT.07 Sambaliung Pada Tanggal : 27 April 2014
SURAT PERINTAH PERJALANAN DINAS Ke : inaran
Nomor : 019/KLG / PKM - SBL / IV / 2014
1. Pejabat yang berwenang memberikan perintah : Kepala Puskesmas Sambaliung
2. Nama Pegawai yang diperintahkan : #N/A
3. a. NIP : #N/A H. Syafrudin. AB
b. Pangkat dan golongan menurut PGPS, 1968 : #N/A NIP. 19590102 198201 1 008
c. Jabatan : #N/A II. Tiba di : inaran Berangkat dari :
d. Tingkat Menurut Peraturan Perjalanan Dinas : Lokal Pada Tanggal : 27 April 2014 Ke :
4. Maksud Perjalanan Dinas : Kegiatan Pely. luar gedung Kepala : Pada Tanggal :
Kepala :
5. Alat angkut yang dipergunakan : Kendaraan Umum
6. a. Tempat berangkat : Puskesmas Sambaliung .......................................
b. Tempat tujuan : inaran
7. a. Lamanya Perjalanan Dinas : 1 ( satu ) Hari III. Tiba di : Berangkat dari :
b. Tanggal berangkat : 27 April 2014 Pada Tanggal : Ke :
c. Tanggal harus kembali : 27 April 2014 Kepala : Pada Tanggal :
8. Pengikut : Nama : Kepala :

9. Pembenaan Anggaran : APBD II IV. Tiba Kembali di : Telah diperiksa dengan keterangan bahwa perjalanan
a. Instansi : Dinas Kesehatan Kab. Berau Tersebut diatas benar dilakukan atas perintahnya dan
b. Mata Anggaran : 2014 semata -mata untuk kepentingan jabatan dalam waktu
10 Keterangan lain-lain : sesingkat-singkatnya

Catatan: PEJABAT YANG MEMBERI PERINTAH


1. SPPD ini harus diketahui tanggal tiba dan PADA TANGGAL : 02 Maret 2014 Kepala Puskesmas Sambaliung
berangkat oleh pejabat setempat yang Kepala Puskesmas Sambaliung V. Catatan lain-lain
dikunjungi setelah sampai di tempat tujuan
2. 2 (dua) hari setelah tiba kembali ditempat semula H. Syafrudin. AB
SPPD harus diserahkan kembali kepada yang H. Syafrudin. AB NIP. 19590102 198201 1 008
memberikan biaya perjalanan NIP. 19590102 198201 1 008 PERHATIAN :
Apabila perintah bepergian diberikan untuk bepergian yang tidak perlu untuk bepergian ongkosnya menurut
peraturan tidak dapat dibayar oleh PEMDA, maka yang memerintahkan Bertanggung jawab atas ongkosnya yang
dikeluarkan (Lihat Artikel No. 74 dari UU.ICW.)

PEMERINTAH KABUPAEN BERAU Lamp.VI (2 dari 4) Kepmen Keuangan tentang Perjalanan Dinas Dalam Negeri bagi Pejabat Negara Pegawai Negeri Sipil
DINAS KESEHATAN dan Pegawai Tidak Tetap Nomor :7/KMK 02/2003,tanggal 3 Januari 2003
PUSKESMAS SAMBALIUNG I. Berangkat dari tempat kedudukan
Jl.Mangkubumi II RT.07 Sambaliung Pada Tanggal : 27 April 2014
SURAT PERINTAH PERJALANAN DINAS Ke : inaran
Nomor : 019/KLG / PKM - SBL / IV / 2014
1. Pejabat yang berwenang memberikan perintah : Kepala Puskesmas Sambaliung
2. Nama Pegawai yang diperintahkan : #N/A
3. a. NIP : #N/A H. Syafrudin. AB
b. Pangkat dan golongan menurut PGPS, 1968 : #N/A NIP. 19590102 198201 1 008
c. Jabatan : #N/A II. Tiba di : inaran Berangkat dari :
d. Tingkat Menurut Peraturan Perjalanan Dinas : Lokal Pada Tanggal : 27 April 2014 Ke :
4. Maksud Perjalanan Dinas : Kegiatan Pely. luar gedung Kepala : Pada Tanggal :
Kepala :

5. Alat angkut yang dipergunakan : Kendaraan Umum


6. a. Tempat berangkat : Puskesmas Sambaliung .......................................
b. Tempat tujuan : inaran
7. a. Lamanya Perjalanan Dinas : 1 ( satu ) Hari III. Tiba di : Berangkat dari :
b. Tanggal berangkat : 27 April 2014 Pada Tanggal : Ke :
c. Tanggal harus kembali : 27 April 2014 Kepala : Pada Tanggal :
8. Pengikut : Nama : Kepala :

9. Pembenaan Anggaran : APBD II IV. Tiba Kembali di : Telah diperiksa dengan keterangan bahwa perjalanan
a. Instansi : Dinas Kesehatan Kab. Berau Tersebut diatas benar dilakukan atas perintahnya dan
b. Mata Anggaran : 2014 semata -mata untuk kepentingan jabatan dalam waktu
10 Keterangan lain-lain : sesingkat-singkatnya

Catatan: PEJABAT YANG MEMBERI PERINTAH


1. SPPD ini harus diketahui tanggal tiba dan PADA TANGGAL : 02 Maret 2014 Kepala Puskesmas Sambaliung
berangkat oleh pejabat setempat yang Kepala Puskesmas Sambaliung V. Catatan lain-lain
dikunjungi setelah sampai di tempat tujuan
2. 2 (dua) hari setelah tiba kembali ditempat semula H. Syafrudin. AB
SPPD harus diserahkan kembali kepada yang H. Syafrudin. AB NIP. 19590102 198201 1 008
memberikan biaya perjalanan NIP. 19590102 198201 1 008 PERHATIAN :
Apabila perintah bepergian diberikan untuk bepergian yang tidak perlu untuk bepergian ongkosnya menurut
peraturan tidak dapat dibayar oleh PEMDA, maka yang memerintahkan Bertanggung jawab atas ongkosnya yang
dikeluarkan (Lihat Artikel No. 74 dari UU.ICW.)

PEMERINTAH KABUPAEN BERAU Lamp.VI (2 dari 4) Kepmen Keuangan tentang Perjalanan Dinas Dalam Negeri bagi Pejabat Negara Pegawai Negeri Sipil
DINAS KESEHATAN dan Pegawai Tidak Tetap Nomor :7/KMK 02/2003,tanggal 3 Januari 2003
PUSKESMAS SAMBALIUNG I. Berangkat dari tempat kedudukan
Jl.Mangkubumi II RT.07 Sambaliung Pada Tanggal : 27 April 2014
SURAT PERINTAH PERJALANAN DINAS Ke : inaran
Nomor : 019/KLG / PKM - SBL / IV / 2014
1. Pejabat yang berwenang memberikan perintah : Kepala Puskesmas Sambaliung
2. Nama Pegawai yang diperintahkan : #N/A
3. a. NIP : #N/A H. Syafrudin. AB
b. Pangkat dan golongan menurut PGPS, 1968 : #N/A NIP. 19590102 198201 1 008
c. Jabatan : #N/A II. Tiba di : inaran Berangkat dari :
d. Tingkat Menurut Peraturan Perjalanan Dinas : Lokal Pada Tanggal : 27 April 2014 Ke :
4. Maksud Perjalanan Dinas : Kegiatan Pely. luar gedung Kepala : Pada Tanggal :
Kepala :

5. Alat angkut yang dipergunakan : Kendaraan Umum


6. a. Tempat berangkat : Puskesmas Sambaliung .......................................
b. Tempat tujuan : inaran
7. a. Lamanya Perjalanan Dinas : 1 ( satu ) Hari III. Tiba di : Berangkat dari :
b. Tanggal berangkat : 27 April 2014 Pada Tanggal : Ke :
c. Tanggal harus kembali : 27 April 2014 Kepala : Pada Tanggal :
8. Pengikut : Nama : Kepala :

9. Pembenaan Anggaran : APBD II IV. Tiba Kembali di : Telah diperiksa dengan keterangan bahwa perjalanan
a. Instansi : Dinas Kesehatan Kab. Berau Tersebut diatas benar dilakukan atas perintahnya dan
b. Mata Anggaran : 2014 semata -mata untuk kepentingan jabatan dalam waktu
10 Keterangan lain-lain : sesingkat-singkatnya

Catatan: PEJABAT YANG MEMBERI PERINTAH


1. SPPD ini harus diketahui tanggal tiba dan PADA TANGGAL : 02 Maret 2014 Kepala Puskesmas Sambaliung
berangkat oleh pejabat setempat yang Kepala Puskesmas Sambaliung V. Catatan lain-lain
dikunjungi setelah sampai di tempat tujuan
2. 2 (dua) hari setelah tiba kembali ditempat semula H. Syafrudin. AB
SPPD harus diserahkan kembali kepada yang H. Syafrudin. AB NIP. 19590102 198201 1 008
memberikan biaya perjalanan NIP. 19590102 198201 1 008 PERHATIAN :
Apabila perintah bepergian diberikan untuk bepergian yang tidak perlu untuk bepergian ongkosnya menurut
peraturan tidak dapat dibayar oleh PEMDA, maka yang memerintahkan Bertanggung jawab atas ongkosnya yang
dikeluarkan (Lihat Artikel No. 74 dari UU.ICW.)
Pejabat Negara Pegawai Negeri Sipil

menu

SURAT PERINTAH TUGAS


Nomor : 019KLG / PKM - SBL / IV / 2014 019
inaran
Puskesmas Sambaliung Kepada :
27 April 2014 1. Nama : #N/A 19
NIP : #N/A
Pangkat/ : #N/A
Jabatan : #N/A

...................................... 2. Nama : #N/A 27


NIP : #N/A
Pangkat/ : #N/A
Jabatan : #N/A

: 3. Nama : #N/A 22
NIP : #N/A
Pangkat/ : #N/A
Jabatan : #N/A
ngan keterangan bahwa perjalanan
s benar dilakukan atas perintahnya dan 4. Nama : #N/A 18
untuk kepentingan jabatan dalam waktu NIP : #N/A
sesingkat-singkatnya Pangkat/ : #N/A
Jabatan : #N/A
AT YANG MEMBERI PERINTAH
s Sambaliung 5. Nama : #N/A 18
NIP : #N/A
Pangkat/ : #N/A
Jabatan : #N/A

Tujuan : Pelayanan Luar gedung


nurut Lokasi : inaran 27
snya yang Lama Perjal : -24 Hari
Tanggal Pel : ###
Tanggal Kem: ### 2
gawai Negeri Sipil Demikian Surat Tugas ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Dikeluarkan : Sambaliung
Pada Tangga: ###

Kepala Puskesmas,

inaran H. Syafrudin. AB
Puskesmas Sambaliung NIP. 19590102 198201 1 008
27 April 2014

......................................
ngan keterangan bahwa perjalanan
nar dilakukan atas perintahnya dan
uk kepentingan jabatan dalam waktu

MEMBERI PERINTAH
s Sambaliung

8201 1 008

an ongkosnya menurut
g jawab atas ongkosnya yang

Pejabat Negara Pegawai Negeri Sipil

inaran
Puskesmas Sambaliung
27 April 2014
......................................

ngan keterangan bahwa perjalanan


nar dilakukan atas perintahnya dan
uk kepentingan jabatan dalam waktu

MEMBERI PERINTAH
s Sambaliung

8201 1 008

an ongkosnya menurut
g jawab atas ongkosnya yang

Pejabat Negara Pegawai Negeri Sipil


inaran
Puskesmas Sambaliung
27 April 2014

......................................

ngan keterangan bahwa perjalanan


nar dilakukan atas perintahnya dan
uk kepentingan jabatan dalam waktu

MEMBERI PERINTAH
s Sambaliung
8201 1 008

an ongkosnya menurut
g jawab atas ongkosnya yang

Pejabat Negara Pegawai Negeri Sipil

inaran
Puskesmas Sambaliung
27 April 2014

......................................
ngan keterangan bahwa perjalanan
nar dilakukan atas perintahnya dan
uk kepentingan jabatan dalam waktu

MEMBERI PERINTAH
s Sambaliung

8201 1 008

an ongkosnya menurut
g jawab atas ongkosnya yang
LAMPIRAN PENERIMAAN BIAYA LUMPSUM PETUGAS DALAM RANGKA
KEGIATAN PELAYANAN KESEHATAN LUAR GEDUNG
PUSKESMAS SAMBALIUNG
KECAMATAN SAMBALIUNG
Puskesmas : Sambaliung
Nama Kampung : inaran
Tanggal Pelaksanaan : ###
IV 2014
NO NAMA PETUJABATAN RINCIAN P JUMLAH TANDA TANGAN
BIAYA AKO DITERIMA
1 2 3 4 5 6

1 #N/A #N/A 1 or x 1 hr x ### 1

2 #N/A #N/A 1 or x 1 hr x ### 2

3 #N/A #N/A 1 or x 1 hr x ### 3

4 #N/A #N/A 1 or x 1 hr x ### 4

5 #N/A #N/A 1 or x 1 hr x ### 5

JUMLAH ###

Sambaliung, ###
Kepala Puskesmas Sambaliung

H. SYAFRUDIN. AB
Nip. 19590102 198201 1 008
4 2014 Sunday 4

4 2014 Wednesday 4
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS GUNUNG TABUR
JALAN BANGSAWAN RT. II TELP. (0554) 2703237 GUNUNG TABUR (77352)

SURAT PERINTAH TUGAS


Nomor : 040 / PKM - GNT / TU / I / 2011
Kepada :
1. Nama : Suci permata lesatari,S.Kep
NIP : 198308022008012013
Pangkat/Golongan : Pengatur / II d
Jabatan : Pelaksana Perawat
2. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
3. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
4. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
5. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
6. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
Tujuan :
Lokasi :
Lama Perjalanan : 65 Hari
Tanggal Pelaksanaan : 27 Januari 2011
Tanggal Kembali : 01 April 2011
Demikian Surat Tugas ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Dikeluarkan di : GUNUNG TABUR


Pada Tanggal : 27 Januari 2011
Mengetahui :
Lurah Gunung Tabur, Kepala Puskesmas,

Syarifudin. B dr. Hj. Sulistiawati


NIP. 19570910 197810 1 001 NIP. 19761005 200312 2 005
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas Pelayanan luar gedung

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Kamp. Nyapa indah
a. Lamanya Perjalanan Dinas 1 hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b.
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan Suci permata Lestari,S.Kep
a. NIP a. 198308022008012013
b. Pangkat dan golongan b. Penata Muda / III a
c. Jabatan c. Perawat Pelaksana Lanjutan
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas Kegiatan Pelayanan luar gedung

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Kamp. Nyapa indah
a. Lamanya Perjalanan Dinas 1 ( satu ) Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan Rudiza Pahlawa
a. NIP a. -
b. Pangkat dan golongan b. PTT
c. Jabatan c. Sopir
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas Kegiatan Pelayanan luar gedung

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Kamp. Nyapa indah
a. Lamanya Perjalanan Dinas 1 ( satu ) Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas Kegiatan Pelayanan luar gedung

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Kamp. Nyapa indah
a. Lamanya Perjalanan Dinas 1 ( satu ) Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung


H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008

PEMERINTAH KABUPATEN BERAU


DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas Kegiatan Pelayanan luar gedung

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Kamp. Nyapa indah
a. Lamanya Perjalanan Dinas 1 ( satu ) Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain
Coret yang tidak perlu Ditetapkan di Sambaliung
Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
Berangkat dari : Puskesmas Sambaliung
(tempat kedudukan)
Pada Tanggal : 27 Januari 2016
Ke : Kamp. Nyapa indah
Kepala : Puskesmas Sambaliung

H. Syafrudin. AB
NIP. 19590102 198201 1 008
II. Tiba di : Kamp. Nyapa indah Berangkat dari : Kamp. Nyapa indah
Pada Tanggal : 27 Januari 2016 Ke : Puskesmas Sambaliung
Kepala : Pada Tanggal : 27 Januari 2016
Kepala :

....................................... ......................................

III. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

IV. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

V. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

VI. Tiba Kembali di : Puskesmas Sambaliung Telah diperiksa dengan keterangan bahwa perjalanan
(tempat kedudukan) Tersebut diatas benar dilakukan atas perintahnya dan
Pada Tanggal : 27 Januari 2016 semata -mata untuk kepentingan jabatan dalam waktu
sesingkat-singkatnya
Kepala Puskesmas Sambaliung Kepala Puskesmas Sambaliung

H. Syafrudin. AB H. Syafrudin. AB
Penata TK.I/III d Penata TK.I/III d
NIP. 19590102 198201 1 008 NIP. 19590102 198201 1 008
VII. Catatan lain-lain :

VIII.PERHATIAN :
Pejabat yang berwenang menerbitkan SPD, pegawai yang melakukan perjalanan dinas, para pejabat yang mengesahkan
tanggal berangkat/tiba, serta bendaharawan bertanggung jawab berdasarkan peraturan-peraturan Keuangan Negara
apabila negara menderita rugi akibat kesalahan, kelalaian, dan kealpaannya.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau
AKU BANGGA
MEMBANGUN
BERAU

SURAT PERINTAH TUGAS


Nomor : 013/Kesling/BOK / PKM - SBL / I / 2016

Dasar : Biaya BOK Puskesmas Sambaliung 2016

MEMERINTAHKAN
Kepada :
1. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###

2. Nama : Suci permata Lestari,S.Kep


NIP : 198308022008012013
Pangkat/Golongan : Penata Muda / III a
Jabatan : Perawat Pelaksana Lanjutan

3. Nama : Rudiza Pahlawa


NIP : -
Pangkat/Golongan : PTT
Jabatan : Sopir

4. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###

5. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###

Untuk : Pelayanan luar gedung


Tempat berangkat : Puskesmas Sambaliung
Tempat Tujuan : Kamp. Nyapa indah
Lamanya : 66 hari
Tanggal berangkat : 27 Januari 2016
Tanggal Kembali : 01 April 2016
Beban Anggaran : BOK 2016

Setelah melaksanakan tugas agar membuat laporan.


Demikian Surat Tugas ini diberikan agar dipergunakan sebagaimana mestinya.

Ditetapkan di : Sambaliung
Pada Tanggal : 25 Januari 20

Kepala Puskesmas,
H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau
menu

013 I 2016

27

14

13

21

23

23

26

27 4 1 2016 Saturday

mbaliung 1 4 2016 Saturday


anuari 2016

as,
B
d
1 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIU
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL

Yang bertanda tangan dibawah ini :

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

Berdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak d
bukti-bukti pengeluaran meliputi :

NO URAIAN
1 Transport dari pusk. Ke
2 Uang Harian
JUMLAH

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pel
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembay
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagai

Mengetahui / menyetujui Puskesmas Sambaliung,


Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip.

1
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIU
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL

Yang bertanda tangan dibawah ini :

Nama : Suci permata Lestari,S.Kep


NIP : 198308022008012013
Jabatan : Perawat Pelaksana Lanjutan

Berdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak d
bukti-bukti pengeluaran meliputi :

NO URAIAN
1 Transport dari pusk. Ke
2 Uang Harian
JUMLAH

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pel
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembay
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagai

Mengetahui / menyetujui Puskesmas Sambaliung,


Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016

H. Syafrudin. AB Suci permata Les


NIP. 19590102 198201 1 008 Nip.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIU
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL

Yang bertanda tangan dibawah ini :

Nama : Rudiza Pahlawa


NIP : -
Jabatan : Sopir

Berdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak d
bukti-bukti pengeluaran meliputi :

NO URAIAN
1 Transport dari pusk. Ke
2 Uang Harian
JUMLAH

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pel
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembay
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagai

Mengetahui / menyetujui Puskesmas Sambaliung,


Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016

H. Syafrudin. AB Rudiza Pahl


NIP. 19590102 198201 1 008 Nip.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIU
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL

Yang bertanda tangan dibawah ini :

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

Berdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak d
bukti-bukti pengeluaran meliputi :

NO URAIAN
1 Transport dari pusk. Ke
2 Uang Harian
JUMLAH

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pel
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembay
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagai

Mengetahui / menyetujui Puskesmas Sambaliung,


Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008
H. Syafrudin. AB
NIP. 19590102 198201 1 008 Nip.

PEMERINTAH KABUPATEN BERAU


DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIU
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL

Yang bertanda tangan dibawah ini :

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

Berdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak d
bukti-bukti pengeluaran meliputi :

NO URAIAN
1 Transport dari pusk. Ke
2 Uang Harian
JUMLAH

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pel
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembay
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagai

Mengetahui / menyetujui Puskesmas Sambaliung,


Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016
Mengetahui / menyetujui Puskesmas Sambaliung,
Kepala Puskesmas Sambaliung Pejabat Negara / Pegaw
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjala
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip.
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMA
ERAU TA. 2016

SAMBALIUNG KWITANSI
aliung
1. Th. Anggaran : 2016
IL 2. Bukti Kas No. :
3. Beban MAK :

Sudah terima dari :


Uang sebesar :

3/UKS-II/Pusk-SBL/I/2012 Utuk Pembayaran : Transport dan uang harian dalam ra


Dians ke Kamp. Nyapa indah
ni yang tidak dapat diperoleh Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : Pelayanan luar gedung
JUMLAH Tanggal : 27 Januari 2016
Rp 50,000 Terbilang :
Rp 50,000
Rp 100,000

kan untuk pelaksanaan perjalanan Bendahara Pengeluaran


atas pembayaran,kami bersedia Bantuan Operasional Kesehatan
TA. 2016

nakan sebagaimana mestinya Suci Permata Lestari,S.Kep


Nip. 198308022008012013

,Mengetahui
s Sambaliung, .......2016 Kepala Puskesmas Sambaliung
Negara / Pegawai Negeri Kab. Berau Propinsi Kalimantan Timur
akukan Perjalanan Dinas TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008

#N/A
#N/A
ERAU PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMA
SAMBALIUNG TA. 2016
aliung
KWITANSI
IL
1. Th. Anggaran : 2016
2. Bukti Kas No. :
3. Beban MAK :

Sudah terima dari :


Uang sebesar :
3/UKS-II/Pusk-SBL/I/2012

ni yang tidak dapat diperoleh Utuk Pembayaran : Transport dan uang harian dalam ra
Dians ke Kamp. Nyapa indah
Berdasarkan SPPD
JUMLAH Nomor :
Rp 50,000 Untuk perjalanan dinas : Pelayanan luar gedung
Rp 50,000 Tanggal : ###
Rp 100,000 Terbilang :

kan untuk pelaksanaan perjalanan


atas pembayaran,kami bersedia
Bendahara Pengeluaran
Bantuan Operasional Kesehatan
TA. 2016
nakan sebagaimana mestinya

Suci Permata Lestari,S.Kep


s Sambaliung, .......2016 Nip. 198308022008012013
Negara / Pegawai Negeri
akukan Perjalanan Dinas ,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
ci permata Lestari,S.Kep
NIP. 19590102 198201 1 008
198308022008012013
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMA
TA. 2016

ERAU KWITANSI

SAMBALIUNG 1. Th. Anggaran : 2016


aliung 2. Bukti Kas No. :
3. Beban MAK :
IL

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam ra


Dians ke Kamp. Nyapa indah
3/UKS-II/Pusk-SBL/I/2012 Berdasarkan SPPD
Nomor :
ni yang tidak dapat diperoleh Untuk perjalanan dinas : Pelayanan luar gedung
Tanggal : ###
Terbilang :
JUMLAH
Rp 50,000
Rp 50,000
Rp 100,000 Bendahara Pengeluaran
Bantuan Operasional Kesehatan
kan untuk pelaksanaan perjalanan TA. 2016
atas pembayaran,kami bersedia

Suci Permata Lestari,S.Kep


Nip. 198308022008012013
nakan sebagaimana mestinya
,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016
s Sambaliung, .......2016
Negara / Pegawai Negeri
akukan Perjalanan Dinas H. Syafrudin. AB
NIP. 19590102 198201 1 008

Rudiza Pahlawa
-
ERAU PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMA
SAMBALIUNG TA. 2016
aliung
KWITANSI
IL
1. Th. Anggaran : 2016
2. Bukti Kas No. :
3. Beban MAK :

Sudah terima dari :


Uang sebesar :
3/UKS-II/Pusk-SBL/I/2012

ni yang tidak dapat diperoleh Utuk Pembayaran : Transport dan uang harian dalam ra
Dians ke Kamp. Nyapa indah
Berdasarkan SPPD
JUMLAH Nomor :
Rp 50,000 Untuk perjalanan dinas : Pelayanan luar gedung
Rp 50,000 Tanggal : ###
Rp 100,000 Terbilang :

kan untuk pelaksanaan perjalanan


atas pembayaran,kami bersedia
Bendahara Pengeluaran
Bantuan Operasional Kesehatan
TA. 2016
nakan sebagaimana mestinya

Suci Permata Lestari,S.Kep


s Sambaliung, .......2016 Nip. 198308022008012013
Negara / Pegawai Negeri
akukan Perjalanan Dinas ,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
#N/A
NIP. 19590102 198201 1 008
H. Syafrudin. AB
NIP. 19590102 198201 1 008
#N/A

ERAU PUSKESMAS SAMBALIUNG


KABUPATEN BERAUPROPINSI KALIMA
SAMBALIUNG TA. 2016
aliung
KWITANSI
IL
1. Th. Anggaran : 2016
2. Bukti Kas No. :
3. Beban MAK :

Sudah terima dari :


Uang sebesar :
3/UKS-II/Pusk-SBL/I/2012

ni yang tidak dapat diperoleh Utuk Pembayaran : Transport dan uang harian dalam ra
Dians ke Kamp. Nyapa indah
Berdasarkan SPPD
JUMLAH Nomor :
Rp 50,000 Untuk perjalanan dinas : Pelayanan luar gedung
Rp 50,000 Tanggal : ###
Rp 100,000 Terbilang :

kan untuk pelaksanaan perjalanan


atas pembayaran,kami bersedia
Bendahara Pengeluaran
Bantuan Operasional Kesehatan
TA. 2016
nakan sebagaimana mestinya

Suci Permata Lestari,S.Kep


s Sambaliung, .......2016 Nip. 198308022008012013
Negara / Pegawai Negeri
akukan Perjalanan Dinas ,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
s Sambaliung, .......2016
Negara / Pegawai Negeri
akukan Perjalanan Dinas ,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

#N/A H. Syafrudin. AB
NIP. 19590102 198201 1 008
#N/A
MBALIUNG
KALIMANTAN TIMUR

SI

rian dalam rangka perjalanan


apa indah

Puskesmas Sambaliung,......
Yang Menerima

#N/A
Nip. #N/A

i
mbaliung
ntan Timur

AB
01 1 008
MBALIUNG
KALIMANTAN TIMUR

SI

rian dalam rangka perjalanan


apa indah

Puskesmas Sambaliung,......
Yang Menerima

Suci permata Lestari,S.Kep


Nip. 198308022008012013

i
mbaliung
ntan Timur

AB
01 1 008
MBALIUNG
KALIMANTAN TIMUR

SI

rian dalam rangka perjalanan


apa indah

Puskesmas Sambaliung,......
Yang Menerima

Rudiza Pahlawa
Nip. -

i
mbaliung
ntan Timur

AB
01 1 008
MBALIUNG
KALIMANTAN TIMUR

SI

rian dalam rangka perjalanan


apa indah

Puskesmas Sambaliung,......
Yang Menerima

#N/A
Nip. #N/A

i
mbaliung
ntan Timur

AB
01 1 008
AB
01 1 008

MBALIUNG
KALIMANTAN TIMUR

SI

rian dalam rangka perjalanan


apa indah

Puskesmas Sambaliung,......
Yang Menerima

#N/A
Nip. #N/A

i
mbaliung
ntan Timur

AB
01 1 008
i
mbaliung
ntan Timur

AB
01 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/UKS/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b.
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/UKS/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/UKS/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/UKS/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
Berangkat dari : Puskesmas Sambaliung
(tempat kedudukan)
Pada Tanggal : 27 Januari 2016
Ke : 0
Kepala : Puskesmas Sambaliung

H. Syafrudin. AB
NIP. 19590102 198201 1 008
II. Tiba di : 0 Berangkat dari : 0
Pada Tanggal : 27 Januari 2016 Ke : Puskesmas Sambaliung
Kepala : Pada Tanggal : 01 April 2016
Kepala :

....................................... ......................................

III. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

IV. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

V. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

VI. Tiba Kembali di : Puskesmas Sambaliung Telah diperiksa dengan keterangan bahwa perjalanan
(tempat kedudukan) Tersebut diatas benar dilakukan atas perintahnya dan
Pada Tanggal : 01 April 2016 semata -mata untuk kepentingan jabatan dalam waktu
sesingkat-singkatnya
Kepala Puskesmas Sambaliung Kepala Puskesmas Sambaliung

H. Syafrudin. AB H. Syafrudin. AB
Penata TK.I/III d Penata TK.I/III d
NIP. 19590102 198201 1 008 NIP. 19590102 198201 1 008
VII. Catatan lain-lain :

VIII.PERHATIAN :
Pejabat yang berwenang menerbitkan SPD, pegawai yang melakukan perjalanan dinas, para pejabat yang mengesahkan
tanggal berangkat/tiba, serta bendaharawan bertanggung jawab berdasarkan peraturan-peraturan Keuangan Negara
apabila negara menderita rugi akibat kesalahan, kelalaian, dan kealpaannya.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG m
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau

SURAT PERINTAH TUGAS


Nomor : 040/UKS/BOK / PKM - SBL / I / 2016 040

Dasar : Biaya Operasional BOK Puskesmas Sambaliung Tahun 2016


25
Kepada :
1. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ### 27

2. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ### 24

3. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ### 17

4. Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###
27
Tujuan :
Lokasi :
Lama Perjalanan : 66 Hari 1
Tanggal Pelaksanaan : 27 Januari 2016
Tanggal Kembali : 01 April 2016
Demikian Surat Tugas ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Dikeluarkan di : SAMBALIUNG
Pada Tanggal : 25 Januari 2016

Kepala Puskesmas,

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
menu

I 2016

Berdasarkan Surat
Dengan ini kami m
1.

2.

Demikian pernyat

1 1 2016 Wednesday 1 Me
Kepal
Kab. Be

4 4 2016 Friday 1

NIP.

menu
Berdasarkan Surat
Dengan ini kami m
1.

2.

Demikian pernyat

Me
Kepal
Kab. Be

NIP.
Berdasarkan Surat
Dengan ini kami m
1.

2.

Demikian pernyat

Me
Kepal
Kab. Be

NIP.
Berdasarkan Surat
Dengan ini kami m
1.

2.

Demikian pernyat

Me
Kepal
Kab. Be

NIP.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung
1.
DAFTAR PENGELUARAN RIIL 2.
3.
Yang bertanda tangan dibawah ini :

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan Bendaha
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bantuan Ope
untuk menyetorkan kelebihan tersebut ke Kas Negara. TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya Suci Perm
Nip. 19830

Mengetahui / menyetujui Puskesmas Sambaliung, .......2016


Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip. #N/A
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL 1.


2.
Yang bertanda tangan dibawah ini : 3.

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bendaha
untuk menyetorkan kelebihan tersebut ke Kas Negara. Bantuan Ope
TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya
Suci Perm
Nip. 19830
Mengetahui / menyetujui Puskesmas Sambaliung, .......2016
Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip. #N/A
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL 1.


2.
Yang bertanda tangan dibawah ini : 3.

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bendaha
untuk menyetorkan kelebihan tersebut ke Kas Negara. Bantuan Ope
TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya
Suci Perm
Nip. 19830
Mengetahui / menyetujui Puskesmas Sambaliung, .......2016
Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip. #N/A
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL 1.


2.
Yang bertanda tangan dibawah ini : 3.

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bendaha
untuk menyetorkan kelebihan tersebut ke Kas Negara. Bantuan Ope
TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya
Suci Perm
Nip. 19830
Mengetahui / menyetujui Puskesmas Sambaliung, .......2016
Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip. #N/A
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dians ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : 27 Januari 2016
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep #N/A


Nip. 198308022008012013 Nip. #N/A

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dians ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : ###
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep #N/A


Nip. 198308022008012013 Nip. #N/A

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dians ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : ###
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep #N/A


Nip. 198308022008012013 Nip. #N/A

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dians ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : ###
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep #N/A


Nip. 198308022008012013 Nip. #N/A

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan dr. Lelly Kusumaningrum
a. NIP a. 19790428 201001 2 012
b. Pangkat dan golongan b. Penata Muda Tk. I / III b
c. Jabatan c. Dokter Pertama
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b.
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan Suci permata lesatari,S.Kep
a. NIP a. 198308022008012013
b. Pangkat dan golongan b. Pengatur / II d
c. Jabatan c. Pelaksana Perawat
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 040/Kesling/BOK / PKM - SBL / I / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan #N/A
a. NIP a. #N/A
b. Pangkat dan golongan b. #N/A
c. Jabatan c. #N/A
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas 0

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan 0
a. Lamanya Perjalanan Dinas 66 Hari
b. Tanggal berangkat 27 Januari 2016
c. Tanggal harus kembali 01 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 25 Januari 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
Berangkat dari : Puskesmas Sambaliung
(tempat kedudukan)
Pada Tanggal : 27 Januari 2016
Ke : 0
Kepala : Puskesmas Sambaliung

H. Syafrudin. AB
NIP. 19590102 198201 1 008
II. Tiba di : 0 Berangkat dari : 0
Pada Tanggal : 27 Januari 2016 Ke : Puskesmas Sambaliung
Kepala : Pada Tanggal : 01 April 2016
Kepala :

....................................... ......................................

III. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

IV. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

V. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

VI. Tiba Kembali di : Puskesmas Sambaliung Telah diperiksa dengan keterangan bahwa perjalanan
(tempat kedudukan) Tersebut diatas benar dilakukan atas perintahnya dan
Pada Tanggal : 01 April 2016 semata -mata untuk kepentingan jabatan dalam waktu
sesingkat-singkatnya
Kepala Puskesmas Sambaliung Kepala Puskesmas Sambaliung

H. Syafrudin. AB H. Syafrudin. AB
Penata TK.I/III d Penata TK.I/III d
NIP. 19590102 198201 1 008 NIP. 19590102 198201 1 008
VII. Catatan lain-lain :

VIII.PERHATIAN :
Pejabat yang berwenang menerbitkan SPD, pegawai yang melakukan perjalanan dinas, para pejabat yang mengesahkan
tanggal berangkat/tiba, serta bendaharawan bertanggung jawab berdasarkan peraturan-peraturan Keuangan Negara
apabila negara menderita rugi akibat kesalahan, kelalaian, dan kealpaannya.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau

SURAT PERINTAH TUGAS


Nomor : 040/Kesling/BOK / PKM - SBL / I / 2016 040

Dasar : Biaya Operasional BOK Puskesmas Sambaliung Tahun 2016


25
Kepada :
1 1.Nama : dr. Lelly Kusumaningrum
NIP : 19790428 201001 2 012
Pangkat/Golongan : Penata Muda Tk. I / III b
Jabatan : Dokter Pertama 28

15 2.Nama : Suci permata lesatari,S.Kep


NIP : 198308022008012013
Pangkat/Golongan : Pengatur / II d
Jabatan : Pelaksana Perawat 24

24 3.Nama : ###
NIP : ###
Pangkat/Golongan : ###
Jabatan : ###

Tujuan :
Lokasi :
Lama Perjalanan : 66 Hari
Tanggal Pelaksanaan : 27 Januari 2016 27
Tanggal Kembali : 01 April 2016
Demikian Surat Tugas ini dibuat untuk dapat dipergunakan sebagaimana mestinya.
1
Dikeluarkan di : Sambaliung
Pada Tanggal : 25 Januari 2016

Kepala Puskesmas,

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
menu

I 2016

Berdasarkan Su
Dengan ini kam
1.

2.

Demikian pern

1 2016
Ke
Kab.

4 2016

4 2014 #REF! 4

N
menu 4 2014 #REF! 4
Berdasarkan Su
Dengan ini kam
1.

2.

Demikian pern

Ke
Kab.

N
Berdasarkan Su
Dengan ini kam
1.

2.

Demikian pern

Ke
Kab.

N
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung
1.
DAFTAR PENGELUARAN RIIL 2.
3.
Yang bertanda tangan dibawah ini :

Nama : dr. Lelly Kusumaningrum


NIP : 19790428 201001 2 012
Jabatan : Dokter Pertama

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan Bendaha
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bantuan Ope
untuk menyetorkan kelebihan tersebut ke Kas Negara. TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya Suci Perm
Nip. 19830

Mengetahui / menyetujui Puskesmas Sambaliung, .......2016


Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB dr. Lelly Kusumaningrum


NIP. 19590102 198201 1 008 Nip. 19790428 201001 2 012
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL 1.


2.
Yang bertanda tangan dibawah ini : 3.

Nama : Suci permata lesatari,S.Kep


NIP : 198308022008012013
Jabatan : Pelaksana Perawat

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bendaha
untuk menyetorkan kelebihan tersebut ke Kas Negara. Bantuan Ope
TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya
Suci Perm
Nip. 19830
Mengetahui / menyetujui Puskesmas Sambaliung, .......2016
Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB Suci permata lesatari,S.Kep


NIP. 19590102 198201 1 008 Nip. 198308022008012013
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung

DAFTAR PENGELUARAN RIIL 1.


2.
Yang bertanda tangan dibawah ini : 3.

Nama : #N/A
NIP : #N/A
Jabatan : #N/A

rdasarkan Surat Perintah Tugas tanggal 06 Januari 2012, Nomor: 003/UKS-II/Pusk-SBL/I/2012


ngan ini kami menyatakan dengan sesungguhnya bahwa :
Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bendaha
untuk menyetorkan kelebihan tersebut ke Kas Negara. Bantuan Ope
TA

mikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya
Suci Perm
Nip. 19830
Mengetahui / menyetujui Puskesmas Sambaliung, .......2016
Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB #N/A
NIP. 19590102 198201 1 008 Nip. #N/A
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


dinas ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : 27 Januari 2016
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep dr. Lelly Kusumaningrum


Nip. 198308022008012013 Nip. 19790428 201001 2 012

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


dinas ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : 27 Januari 2016
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep Suci permata lesatari,S.Kep


Nip. 198308022008012013 Nip. 198308022008012013

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2016

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dinas ke 0
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : 0
Tanggal : 27 Januari 2016
Terbilang :

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep #N/A


Nip. 198308022008012013 Nip. #N/A

,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 039/KIA/BOK / PKM - SBL / II / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan 0
a. NIP a. 0
b. Pangkat dan golongan b. 0
c. Jabatan c. 0
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas DITK di PAUD

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Sambaliung
a. Lamanya Perjalanan Dinas 2 hari
b. Tanggal berangkat 22 April 2016
c. Tanggal harus kembali 24 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b.
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 20 April 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jl.Mangkubumi II RT.07 Sambaliung
SURAT PERJALANAN DINAS
Nomor : 039/KIA/BOK / PKM - SBL / II / 2016

Pejabat yang berwenang memberikan perintah Kepala Puskesmas Sambaliung


Nama Pegawai yang diperintahkan dr. Aji Ety Dahlia
a. NIP a. 19781104 201412 2 001
b. Pangkat dan golongan b. 0
c. Jabatan c. 0
d. Tingkat Menurut Peraturan Perjalanan Dinas d. Lokal
Maksud Perjalanan Dinas DITK di PAUD

Alat angkut yang dipergunakan Kendaraan Darat


a. Tempat berangkat Puskesmas Sambaliung
b. Tempat tujuan Sambaliung
a. Lamanya Perjalanan Dinas 2 hari
b. Tanggal berangkat 22 April 2016
c. Tanggal harus kembali 24 April 2016
Pengikut Nama Umur Hubungan keluarga/Keterangan

Pembenaan Anggaran
a. Instansi a. Dinas Kesehatan Kab. Berau
b. Kode Rekening b. 0
Keterangan lain-lain

Coret yang tidak perlu Ditetapkan di Sambaliung


Pada tanggal 20 April 2016

Kepala Puskesmas Sambaliung

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
Berangkat dari : Puskesmas Sambaliung
(tempat kedudukan)
Pada Tanggal : 22 April 2016
Ke : Sambaliung
Kepala : Puskesmas Sambaliung

H. Syafrudin. AB
NIP. 19590102 198201 1 008
II. Tiba di : Sambaliung Berangkat dari : Sambaliung
Pada Tanggal : 22 April 2016 Ke : Puskesmas Sambaliung
Kepala : Pada Tanggal : 22 April 2016
Kepala :

....................................... ......................................

III. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

IV. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

V. Tiba di : Berangkat dari :


Pada Tanggal : Ke :
Kepala : Pada Tanggal :
Kepala :

....................................... ......................................

VI. Tiba Kembali di : Puskesmas Sambaliung Telah diperiksa dengan keterangan bahwa perjalanan
(tempat kedudukan) Tersebut diatas benar dilakukan atas perintahnya dan
Pada Tanggal : 24 April 2016 semata -mata untuk kepentingan jabatan dalam waktu
sesingkat-singkatnya
Kepala Puskesmas Sambaliung Kepala Puskesmas Sambaliung

H. Syafrudin. AB H. Syafrudin. AB
Penata TK.I/III d Penata TK.I/III d
NIP. 19590102 198201 1 008 NIP. 19590102 198201 1 008
VII. Catatan lain-lain :

VIII.PERHATIAN :
Pejabat yang berwenang menerbitkan SPD, pegawai yang melakukan perjalanan dinas, para pejabat yang mengesahkan
tanggal berangkat/tiba, serta bendaharawan bertanggung jawab berdasarkan peraturan-peraturan Keuangan Negara
apabila negara menderita rugi akibat kesalahan, kelalaian, dan kealpaannya.
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSKESMAS SAMBALIUNG
Jalan. Mangkubumi 2 RT.VII, Kec. Sambaliung, Berau

SURAT PERINTAH TUGAS


Nomor : 039/KIA/BOK / PKM - SBL / II / 2016

Dasar : Biaya Operasional BOK Puskesmas Sambaliung Tahun 2016

Kepada :
1. Nama : 0
NIP : 0
Pangkat/Golongan : 0
Jabatan : 0

2. Nama : dr. Aji Ety Dahlia


NIP : 19781104 201412 2 001
Pangkat/Golongan : 0
Jabatan : 0

Tujuan : DITK di PAUD


Lokasi : Sambaliung
Lama Perjalanan : 2 hari
Tanggal Pelaksanaan : 22 April 2016
Tanggal Kembali : 24 April 2016
Demikian Surat Tugas ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Dikeluarkan di : Sambaliung
Pada Tanggal : 20 April 2016

Kepala Puskesmas,

H. Syafrudin. AB
Penata TK.I/III d
NIP. 19590102 198201 1 008
menu

039 II 2016

22 4 4 2016 Friday 2

24 4 4 2016 Sunday 2

menu
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung
1.
DAFTAR PENGELUARAN RIIL 2.
3.
Yang bertanda tangan dibawah ini :

Nama : 0
NIP : 0
Jabatan : 0

Berdasarkan Surat Perintah Tugas tanggal 11 Februari 2016, Nomor: 039/KIA/BOK/Pusk-SBL/I/2016


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke PAUD sambaliung Rp 50,000
2 Uang Harian Rp 50,000
JUMLAH Rp 100,000

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan Bend
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bantuan
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya Suci P
Nip. 1

Mengetahui / menyetujui Puskesmas Sambaliung, ..................2016


Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB 0
NIP. 19590102 198201 1 008 Nip. 0
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt VII Sambaliung
1.
DAFTAR PENGELUARAN RIIL 2.
3.
Yang bertanda tangan dibawah ini :

Nama : dr. Aji Ety Dahlia


NIP : 19781104 201412 2 001
Jabatan : 0

Berdasarkan Surat Perintah Tugas tanggal 11 Februari 2016, Nomor: 039/KIA/BOK/Pusk-SBL/I/2016


Dengan ini kami menyatakan dengan sesungguhnya bahwa :
1. Biaya transport pegawai dan / atau biaya penginapan dibawah ini yang tidak dapat diperoleh
bukti-bukti pengeluaran meliputi :

NO URAIAN JUMLAH
1 Transport dari pusk. Ke PAUD sambaliung Rp 50,000
2 Uang Harian Rp 75,000
JUMLAH Rp 125,000

2. Jumlah uang tersebut pada angka 1 di atas benar-benar dikeluarkan untuk pelaksanaan perjalanan Bend
dinas dimaksud dan apabila dikemudian hari terdapat kelebihan atas pembayaran,kami bersedia Bantuan
untuk menyetorkan kelebihan tersebut ke Kas Negara.

Demikian pernyataan ini kami buta dengan sebenarnya, untuk dipergunakan sebagaimana mestinya Suci P
Nip. 1

Mengetahui / menyetujui Puskesmas Sambaliung, ............2016


Kepala Puskesmas Sambaliung Pejabat Negara / Pegawai Negeri
Kab. Berau Prop. Kalimantan Timur Yang melakukan Perjalanan Dinas
TA.2016

H. Syafrudin. AB dr. Aji Ety Dahlia


NIP. 19590102 198201 1 008 Nip. 19781104 201412 2 001
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2011

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :
Rp 100,000

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dinas ke Sambaliung
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : DITK di PAUD
Tanggal : 22 April 2016
Terbilang :
Seratus Ribu Rupiah

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep 0


Nip. 198308022008012013 Nip. 0
PUSKESMAS SAMBALIUNG
KABUPATEN BERAUPROPINSI KALIMANTAN TIMUR
TA. 2011

KWITANSI

Th. Anggaran : 2016


Bukti Kas No. :
Beban MAK :

Sudah terima dari :


Uang sebesar :
Rp 125,000

Utuk Pembayaran : Transport dan uang harian dalam rangka perjalanan


Dinas ke Sambaliung
Berdasarkan SPPD
Nomor :
Untuk perjalanan dinas : DITK di PAUD
Tanggal : 22 April 2016
Terbilang :
Seratus Ribu Rupiah

Puskesmas Sambaliung,......
Bendahara Pengeluaran Yang Menerima
Bantuan Operasional Kesehatan
TA. 2016

Suci Permata Lestari,S.Kep dr. Aji Ety Dahlia


Nip. 198308022008012013 Nip. 19781104 201412 2 001
,Mengetahui
Kepala Puskesmas Sambaliung
Kab. Berau Propinsi Kalimantan Timur
TA.2016

H. Syafrudin. AB
NIP. 19590102 198201 1 008
PEMERINTAH KABUPATEN BERAU
DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT SAMBALIUNG
Jl. Mangkubumi II Rt.VIISambaliung,77371
email : puskesmassambaliung@gmail.com FB : puskesmassambaliung

PUSKESMAS : SAMBALIUNG
NOMOR : 340 /TU-III/ PKM-SBL /VIII /2017 0

SURAT KETERANGAN KESEHATAN

Yang bertanda tangan di bawah ini, dokter umum pemeriksa kesehatan dalam hal ini menjalankan
tugasnya dengan mengikat sumpah yang telah diucapkan sewaktu menerima jabatan, dengan ini
menerangkan bahwa telah memeriksa dengan teliti seseorang :

Nama : Muh. Risal


Tempat/Tanggal Lahir : Cilellang, 06 Februari 1989
Jenis kelamin : Laki-laki
Pekerjaan : Belum/Tidak Bekerja
Alamat : Sambaliung
Permintaan : Sendiri

Dengan Nomor Surat... Tanggal


Dengan berpendapat bahwa yang bersangkutan dalam keadaan sehat jasmani dan rohani
Surat keterangan ini dibuat untuk : Melamar Pekerjaan
Yang bersangkutan dalam kelas II dalam lampiran AI KEURING-REGLEMENT.

Demikian Surat Keterangan ini dibuat untuk dapat dipergunakan sebagaimana mestinya

Dikeluarkan di Sambaliung
Pada Tanggal : 19 September 2017
Dokter Pemeriksa

dr. Fredy Setyawan


NIP. ..........................................

Surat keterangan ini berlaku hanya 3 (tiga) bulan sejak tanggal dikeluarkan
Berlaku sejak tanggal :
Sampai dengan : 19 September 2017
19 Desember 2017

Keterangan :
: BB : 58.5 Kg
: TB : 183.5 Cm
:
: Gol. Darah
Bebas Buta Warna
340 IX A

2
2

PEKERJAAN
Q19
J19 Laki-laki Pelajar/Mahasiswa
J20 Perempuan Q21
Pegawai Negeri Sipil (PNS)
Q23
Ibu Rumah Tangga
J24 Perpanjangan SIM Q25
J25 Melamar Pekerjaan Karyawan Swasta
J26 Melanjutkan Pendidikan
J27 Persyaratan Nikah

TANGGAL
19 9 2017 Saturday

J50 Bebas Buta Warna


J51 Buta Warna Parsial
DATA PEGAWAI PUSKESMAS Sambaliung

NO NAMA NIP PANGKAT / GOLONGAN


1 dr. Lelly Kusumaningrum 19790428 201001 2 012 Penata Muda Tk. I / III b
2 dr. Fredy Setyawan ..........................................
3 dr. Wiwin 19810825 200803 2 002
4 dr. Aji Ety Dahlia 19781104 201412 2 001

5
6
7
8
9
10
1 Pelajar/Mahasiswa 19761005 200312 2 005 Penata Tk. I / III d
2 Pegawai Negeri Sipil (PNS 19800226 200012 2 001 Penata Muda / III a
3 Mengurus Rumah Tangga 19810102 200502 2 002 Pengatur Tk. I / II d
4 Petani/Pekebun 19810417 200502 2 007 Pengatur Tk. I / II d
5 Karyawan Swasta 19750311 200604 1 007 Pengatur Tk. I / II d
6 Karyawan Honorer 19750321 200604 2 018 Pengatur Tk. I / II d
7 19850623 201001 2 008 Pengatur Tk. I / II d
8 19710808 200701 1 015 Pengatur Muda TK. I / II b
9 19851109 200701 2 001 Pengatur Muda TK. I / II b
10 Ismini,Amd.Kep - PTT
11 Widya Lestari,Amd.KL - PTT
12 Santi 198511092007012001 Pengatur/ II c
13 Rudiza Pahlawa - PTT
14 Suci permata Lestari,S.Kep 198308022008012013 Penata Muda / III a
15 Suci permata lesatari,S.Kep 198308022008012013 Pengatur / II d
01 January 2010 40179
02 January 2010 40180 Column1
12 January 2010 40190 10 March 2010
29 January 2010 40207
30 January 2010 40208
31 January 2010 40209
01 February 2010 40210
02 February 2010 40211
03 February 2010 40212
04 February 2010 40213
05 February 2010 40214
06 February 2010 40215
07 February 2010 40216
08 February 2010 40217
09 February 2010 40218
10 February 2010 40219
11 February 2010 40220
12 February 2010 40221
13 February 2010 40222
14 February 2010 40223
15 February 2010 40224
16 February 2010 40225
17 February 2010 40226
18 February 2010 40227
19 February 2010 40228
20 February 2010 40229
21 February 2010 40230
22 February 2010 40231
23 February 2010 40232
24 February 2010 40233
25 February 2010 40234
26 February 2010 40235
27 February 2010 40236
28 February 2010 40237
01 March 2010 40238
02 March 2010 40239
03 March 2010 40240
04 March 2010 40241
05 March 2010 40242
06 March 2010 40243
07 March 2010 40244
08 March 2010 40245
09 March 2010 40246
10 March 2010 40247
11 March 2010 40248
12 March 2010 40249
13 March 2010 40250
14 March 2010 40251
15 March 2010 40252
16 March 2010 40253
17 March 2010 40254
18 March 2010 40255
19 March 2010 40256
20 March 2010 40257
21 March 2010 40258
22 March 2010 40259
23 March 2010 40260
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