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VARIABEL KETENAGAAN

Isian Ketenagaan Skor


1 Tenaga Medis 150
2 Apoteker 100
3 Ners 100
4 Nakes setara S1/D4 60
5 Non Nakes minimal setara D3 40
Nakes setara D3 40
Nakes dibawah D3 dengan masa kerja > 10 Thn 40
6 Nakes dibawah D3 25
7 Non Nakes dibawah D3 15
VARIABEL JABATAN (Merangkap Tugas Administratif)
Isian Jabatan Skor
Tidak Merangkap Tugas dalam Kegiatan BPJS 0
1 Kepala Puskesmas : 1. Dokter (Tenaga Medis) 30
VARIABEL KEHADIRAN
Isian BULAN Hari Merah Hari Kerja Efektif
1 Januari 31 7 24
2 Pebruari 28 4 24
3 Maret 31 6 25
4 April 30 5 25
5 Mei 31 8 23
6 Juni 30 5 25
7 Juli 31 6 25
8 Agustus 31 5 26
9 September 30 4 26
10 Oktober 31 5 26
11 Nopember 30 5 25
12 Desember 31 5 26
VARIABEL KINERJA KEPALA PUSKESMAS (FKTP)
1 Akreditasi Puskesmas
No Akreditasi Puskesmas Skor
1 Paripurna 75
2 Utama 50
3 Madya 30
4 Dasar 15
5 Tidak Terakreditasi 5

2 Penilaian Kinerja Puskesmas (PKP)


No Penilaian Kinerja Puskesmas Skor
1 Baik (Cak. > 90 %) 50
2 Sedang (Cak. 81 - 90 %) 30
3 Kurang (Cak. <= 80 %) 15

3 Penilaian Indeks Kepuasan Masyarakat (IKM)


Isian Indeks Kepuasan Masyarakat Skor
1 Sangat Baik (Nilai Konversi : 81,26 - 100,00) 25
2 Baik (Nilai Konversi : 62,51 - 81,25) 20
3 Kurang Baik (Nilai Konversi : 43,76 - 62,50) 15
4 Tidak Baik (Nilai Konversi : 25,00 - 43,75) 10
VARIABEL STATUS KEPEGAWAIAN
Isian Status Kepegawaian Skor
1 Pegawai Negeri Sipil (PNS) 100
2 Non PNS : Pegawai Tidak Tetap (PTT) 60
3 Non PNS : Honorer/Sukarelawan 25
VARIABEL MASA KERJA
Isian Masa Kerja (Pembulatan Bulan) Tahun
1 < 6 Bulan 0
2 > = 6 Bulan 1

Masa Kerja Maksimal (Tahun) 30


100
PAJAK PPh (%)
Isian Golongan NPWP Non NPWP
0 5% PTT, Honorer/Sukwan
1 I 0% PNS
2 II 0% PNS
3 III 5% PNS
4 IV 15% PNS
PUSKESMAS Kepuh Nama Bendahara Dana Kapitasi BPJS
BULAN (Isi dengan angka) 10 Oktober NIP
TAHUN 2014 26 Nama Kepala Puskesmas
TOTAL JASPEL (60%) 44,213,400.00 NIP

Ketenagaan Ketidakhadiran Ketenagaan


No Nama NIP Gol.
Jabatan (dlm 1 Bulan) Jabatan BPJS

Tenaga Medis / Kepala Puskesmas

1 dr. H. Edi Susanto 19780424 200604 1 017 3 Kepala Puskesmas 0 Hari 1


2 dr. Feronila Pardede 0 dokter Umum 0 Hari
3 dr. Siti Kodija 0 dokter Umum 0 Hari
4
5
6
7
8
9
10
Tenaga Apoteker

1
2
3
4
5
6
7
8
9
10
Tenaga Profesi Keperawatan (Ners)

1 Subhana, S.Kep.Ners. 19751012 200701 1 007 3 TU 0 Hari 8


2
3
4
5
6
7
8
9
10
11
12
13
14
15
Tenaga Kesehatan (S1/D4)

1 Ilawati 19750415 199503 2 002 3 Bend.BPJS 0 Hari 8


2 Wandi Furqoni Sanitasi 1 Hari
3 Dewi Nur Sobariyah 19890801 200902 2 001 2 Farmasi 0 Hari
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Tenaga Non Kesehatan Minimal setara D3/Kesehatan : (Setara D3, D3 atau dibawah D3 dengan
masa kerja > 10 Th)

1 Ngasiyah 19680420 199301 2 002 3 Bidan 26 Hari


2 Kurnaesih 19710704 200112 2 001 3 Perawat 0 Hari
3 Reni Ariyanti 19751005 200003 2 002 3 Perawat 0 Hari
4 Mohamad Ardi 19731028 199703 1 002 3 Perawat 0 Hari
5 Sri Sekarkuningsih 19750730 199503 2 001 3 Sanitasi 2 Hari
6 Supiah 19760417 200701 2 006 3 Perawat 26 Hari
7 Neneng Susanah 19800922 200701 2 002 3 Perawat 1 Hari
8 Carminah 19800804 200801 2 007 2 Perawat 1 Hari
9 Sri Eviyani 19810209 200801 2 004 2 Perawat 0 Hari
10 Yuly Tresnawiati 19760729 200112 2 006 2 Pranata Labkes. 1 Hari
11 Anisa Nurzanah 19790512 201001 2 009 2 Perawat 0 Hari
12 Nani Juniarti 19790608 200801 2 009 2 Bidan 0 Hari
13 Eep Repiyanti 19810127 200801 2 006 2 Perawat 0 Hari
14 Darmini 0 Bidan 0 Hari
15 Lilis Komalasari 0 Bidan 0 Hari
16 Heni Oktaviani 0 Bidan 0 Hari
17 Iis Istianah 0 Bidan 0 Hari
18 Tuti Rohati 0 Bidan 0 Hari
19 Iah Solihah 0 bidan 0 Hari
20 Marwati 0 Bidan 0 Hari
21 Fujiyati Sri. U. 0 Bidan 1 Hari
22 Eka Wulandari 0 bidan 0 Hari
23 Nuryanti 0 Bidan 1 Hari
24 Endang Istiqomah 0 Bidan 0 Hari
25 Siti Murni 0 Bidan 0 Hari
26 Yayah Marwiyah 0 Bidan 0 Hari
27 Vini Vuri Asih 0 Bidan 0 Hari
28 Sinta Ayu Dewi A.W. 0 Bidan 0 Hari
29 Ita Yutika 0 Bidan 0 Hari
30 Susila Sri Dewi.M. 0 Bidan 0 Hari
31 Vivi Nurluthfiah 0 Bidan 0 Hari
32 Iip Masripah 0 Bidan 0 Hari
33 Nurjanah 0 Bidan 0 Hari
34 Sudin 0 Perawat 0 Hari
35 Sri maela 0 Perawat 2 Hari
36 Evi Nurprihatin 0 Perawat 0 Hari
37 Yudhi Febriyanto 0 Perawat 0 Hari
38 Sari Sulistyowati 0 Gizi 0 Hari
39 Yuyun Purota`ayun 0 Perawat 1 Hari
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
Tenaga Kesehatan dibawah D3

1 Edi Suprapto 19720514 200604 1 007 2 Perawat 0 Hari


2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Tenaga Non Kesehatan dibawah D3

1 Subakti 0 Administrasi Umum 0 Hari


2 Sarka 0 Administrasi Umum 0 Hari
3 Tati Rohayati 0 Administrasi Umum 1 Hari
4 Julaekha 0 Administrasi Umum 0 Hari
5 Sri Rahayu 0 Administrasi Umum 0 Hari
6 Ani Yuliani 0 Administrasi Umum 1 Hari
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
Jumlah
3
Ilawati
19750415 199503 2 002 Kinerja Ka. Pusk.
dr. H. Edi Susanto 80
19780424 200604 1 017 =1 >0

KINERJA KA.PUSK. KINERJA STATUS MASA


NO. NPWP 53
Akreditasi PKP IKM KARYAWAN PEGAWAI KERJA
Harus Pakai Rumus 3
3 2 2 0 1 8 14.301.503.0-426.000 1
0 0 0 45 2 5 70.665.611..3-426.000 1
0 0 0 45 2 2 45.973355.6-426.000 1
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
1
0 0 0 30 1 7 57.595.596.8-426.000 3
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
3
0 0 0 30 1 19 57.595.591.9-426.000 4
0 0 0 10 3 4 70.687.234.8-426.000 4
0 0 0 15 1 5 36.172.736.9.426.000 4
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -

39
0 0 0 15 1 21 57.595.585.1-426.000 5
0 0 0 15 1 14 57.595.587.7-426.000 5
0 0 0 10 1 14 57.595.588.5-426.000 5
0 0 0 10 1 17 57.595.589.3-426.000 5
0 0 0 10 1 19 57.595.590.1-426.000 5
0 0 0 15 1 7 58.084.292.0-426.000 5
0 0 0 15 1 7 57.595.597.6-426.000 5
0 0 0 10 1 6 67.719.260.1-426.000 5
0 0 0 15 1 6 67.719.260.1-426.000 5
0 0 0 25 1 14 57.595.593.5-426.000 5
0 0 0 15 1 4 36.375.191.8-426.000 5
0 0 0 10 1 6 57.595.601.6-426.000 5
0 0 0 10 1 6 57.595.602.4-426.000 5
0 0 0 10 2 8 36.793.962.6-426.001 5
0 0 0 10 2 6 24.906.386.8-426.001 5
0 0 0 10 2 3 36.548.056.5-426.000 5
0 0 0 10 2 5 36.186.328.5-426.000 5
0 0 0 10 2 5 55.386.126.1-426.000 5
0 0 0 10 2 5 36.186.328.5-426.000 5
0 0 0 10 2 7 34.492.897.3-426.001 5
0 0 0 10 3 4 70.670.070.5-438.000 5
0 0 0 10 3 3 70.675.520.4-426.000 5
0 0 0 10 3 3 25.730.504.5-426.001 5
0 0 0 10 3 3 70.675.383.7-426.000 5
0 0 0 10 3 2 70.652.675.3-426.000 5
0 0 0 10 3 2 70.676.882.7-426.000 5
0 0 0 10 3 2 70.657.963.8-426.000 5
0 0 0 10 3 2 70.651.797.6-426.000 5
0 0 0 10 3 2 70.688.828.6-426.000 5
0 0 0 10 3 3 70.675.632.7-426.000 5
0 0 0 10 3 2 70.675.578.2-426.000 5
0 0 0 10 3 1 70.684.419.8-426.000 5
0 0 0 10 3 1 70.651.485.8-426.000 5
0 0 0 10 2 7 16.954.415.2-426.000 5
0 0 0 10 3 6 64.296.125.4-426.999 5
0 0 0 10 3 2 70.675.469.4-426.000 5
0 0 0 10 3 3 55.280.566.5-426.000 5
0 0 0 10 3 2 68.486.424.3-401.000 5
0 0 0 10 3 1 66.011.400.0-426.000 5
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
1
0 0 0 10 1 8 57.595.595.0-426.000 6
0 0 0 - -
0 0 0
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
6
0 0 0 10 3 11 16.954.416.0-426.000 7
0 0 0 10 3 24 16.954.418.6-426.000 7
0 0 0 15 2 7 16.954.414.5-426.000 7
0 0 0 10 3 11 16.954.423.7-426.000 7
0 0 0 10 3 12 70.680.171.9-426.000 7
0 0 0 10 3 13 16.954.417.8-426.000 7
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
0 0 0 - -
3 2 2
Masa Kerja 24
Tertinggi
44,213,400.00

44,213,400.00
0.00
Rumus I Rumus II Rumus III Jumlah Rumus IV Pajak Yg Diterima Bagi Rata
180 26 213.33 419.33 2,045,624.71 102,281.24 1,943,343.47 0
150 26 125.83 301.83 1,472,427.01 73,621.35 1,398,805.66 0
150 26 113.33 289.33 1,411,448.53 70,572.43 1,340,876.10 0

130 26 159.17 315.17 1,537,470.72 76,873.54 1,460,597.18 0

90 26 209.17 325.17 1,586,253.50 79,312.68 1,506,940.83 0


58 25 51.67 134.36 655,440.47 #N/A #N/A 0
60 26 135.83 221.83 1,082,164.74 0.00 1,082,164.74 0
0 0 202.50 202.50 987,851.36 49,392.57 938,458.79 0
40 26 173.33 239.33 1,167,534.61 58,376.73 1,109,157.88 0
40 26 168.33 234.33 1,143,143.22 57,157.16 1,085,986.06 0
40 26 180.83 246.83 1,204,121.70 60,206.08 1,143,915.61 0
37 24 189.17 250.09 1,220,007.38 61,000.37 1,159,007.01 0
0 0 144.17 144.17 703,285.13 35,164.26 668,120.87 0
38 25 144.17 207.63 1,012,868.17 50,643.41 962,224.76 0
38 25 135.00 198.46 968,150.62 0.00 968,150.62 0
40 26 140.00 206.00 1,004,925.33 0.00 1,004,925.33 0
38 25 183.33 246.79 1,203,934.07 0.00 1,203,934.07 0
40 26 131.67 197.67 964,273.02 0.00 964,273.02 0
40 26 135.00 201.00 980,533.94 0.00 980,533.94 0
40 26 135.00 201.00 980,533.94 0.00 980,533.94 0
40 26 103.33 169.33 826,055.13 41,302.76 784,752.37 0
40 26 95.00 161.00 785,402.81 39,270.14 746,132.67 0
40 26 82.50 148.50 724,424.33 36,221.22 688,203.11 0
40 26 90.83 156.83 765,076.65 38,253.83 726,822.82 0
40 26 90.83 156.83 765,076.65 38,253.83 726,822.82 0
40 26 90.83 156.83 765,076.65 38,253.83 726,822.82 0
40 26 99.17 165.17 805,728.97 40,286.45 765,442.52 0
38 25 51.67 115.13 561,627.43 28,081.37 533,546.06 0
40 26 47.50 113.50 553,684.59 27,684.23 526,000.36 0
38 25 47.50 110.96 541,301.27 27,065.06 514,236.20 0
40 26 47.50 113.50 553,684.59 27,684.23 526,000.36 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 47.50 113.50 553,684.59 27,684.23 526,000.36 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 39.17 105.17 513,032.27 25,651.61 487,380.66 0
40 26 39.17 105.17 513,032.27 25,651.61 487,380.66 0
40 26 99.17 165.17 805,728.97 40,286.45 765,442.52 0
37 24 60.00 120.92 589,896.43 29,494.82 560,401.60 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
40 26 47.50 113.50 553,684.59 27,684.23 526,000.36 0
40 26 43.33 109.33 533,358.43 26,667.92 506,690.51 0
38 25 39.17 102.63 500,648.95 25,032.45 475,616.50 0
25 26 143.33 194.33 948,012.09 0.00 948,012.09 0
15 26 80.83 121.83 594,336.91 29,716.85 564,620.06 0
15 26 135.00 176.00 858,576.99 42,928.85 815,648.14 0
14 25 104.17 143.59 700,470.73 35,023.54 665,447.20 0
15 26 80.83 121.83 594,336.91 29,716.85 564,620.06 0
15 26 85.00 126.00 614,663.07 30,733.15 583,929.92 0
14 25 89.17 128.59 627,296.56 31,364.83 595,931.73 0
9,063.32 44,213,400.00 #N/A #N/A 0.00
44,213,400.00 44,213,400.00
0.00 0.00
Yang Diterima
1,943,343.47 1 8
1,398,805.66 - -
1,340,876.10 - -
- -
- -
- -
- -
- -
- -
- -

- -
- -
- -
- -
- -
- -
- -
- -
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1,460,597.18 1 7
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

1,506,940.83 1 19
#N/A - -
1,082,164.74 1 5
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -
- -

938,458.79 1 21
1,109,157.88 1 14
1,085,986.06 1 14
1,143,915.61 1 17
1,159,007.01 1 19
668,120.87 1 7
962,224.76 1 7
968,150.62 1 6
1,004,925.33 1 6
1,203,934.07 1 14
964,273.02 1 4
980,533.94 1 6
980,533.94 1 6
784,752.37 - -
746,132.67 - -
688,203.11 - -
726,822.82 - -
726,822.82 - -
726,822.82 - -
765,442.52 - -
533,546.06 - -
526,000.36 - -
514,236.20 - -
526,000.36 - -
506,690.51 - -
506,690.51 - -
506,690.51 - -
506,690.51 - -
506,690.51 - -
526,000.36 - -
506,690.51 - -
487,380.66 - -
487,380.66 - -
765,442.52 - -
560,401.60 - -
506,690.51 - -
526,000.36 - -
506,690.51 - -
475,616.50 - -
- -
- -
- -
- -
- -
- -
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948,012.09 1 8
- -
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- -

564,620.06 - -
815,648.14 - -
665,447.20 - -
564,620.06 - -
583,929.92 - -
595,931.73 - -
- -
- -
- -
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- -
44,213,400.00
0.00
Daftar Penerimaan Jasa Pelayanan
Dana Kapitasi BPJS Pada FKTP Puske
Bulan Oktober 2014

Ketenagaan Ketidakhadiran Jumlah Besar Pene


No Nama NIP Gol.
Jabatan (dlm 1 Bulan) Point Jasa Pela
Tenaga Medis / Kepala Puskesmas
1 dr. H. Edi Susanto 19780424 200604 1 017 III Kepala Puskesmas - Hari 419.33 Rp.
2 dr. Feronila Pardede - - dokter Umum - Hari 301.83 Rp.
3 dr. Siti Kodija - - dokter Umum - Hari 289.33 Rp.
4
5
6
7
8
9
10
Tenaga Apoteker

1
2
3
4
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Tenaga Profesi Keperawatan (Ners)

1 Subhana, S.Kep.Ners. 19751012 200701 1 007 III TU - Hari 315.17 Rp.


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Tenaga Kesehatan (S1/D4)

1 Ilawati 19750415 199503 2 002 III Bend.BPJS - Hari 325.17 Rp.


2 Wandi Furqoni - Sanitasi 1 Hari 134.36 Rp.
3 Dewi Nur Sobariyah 19890801 200902 2 001 II Farmasi - Hari 221.83 Rp.
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Tenaga Non Kesehatan Minimal setara D3/Kesehatan : (Setara D3, D3 atau dibawah D3 dengan
masa kerja > 10 Th)

1 Ngasiyah 19680420 199301 2 002 III Bidan 26 Hari 202.50 Rp.


2 Kurnaesih 19710704 200112 2 001 III Perawat - Hari 239.33 Rp.
3 Reni Ariyanti 19751005 200003 2 002 III Perawat - Hari 234.33 Rp.
4 Mohamad Ardi 19731028 199703 1 002 III Perawat - Hari 246.83 Rp.
5 Sri Sekarkuningsih 19750730 199503 2 001 III Sanitasi 2 Hari 250.09 Rp.
6 Supiah 19760417 200701 2 006 III Perawat 26 Hari 144.17 Rp.
7 Neneng Susanah 19800922 200701 2 002 III Perawat 1 Hari 207.63 Rp.
8 Carminah 19800804 200801 2 007 II Perawat 1 Hari 198.46 Rp.
9 Sri Eviyani 19810209 200801 2 004 II Perawat - Hari 206.00 Rp.
10 Yuly Tresnawiati 19760729 200112 2 006 II Pranata Labkes. 1 Hari 246.79 Rp.
11 Anisa Nurzanah 19790512 201001 2 009 II Perawat - Hari 197.67 Rp.
12 Nani Juniarti 19790608 200801 2 009 II Bidan - Hari 201.00 Rp.
13 Eep Repiyanti 19810127 200801 2 006 II Perawat - Hari 201.00 Rp.
14 Darmini - - Bidan - Hari 169.33 Rp.
15 Lilis Komalasari - - Bidan - Hari 161.00 Rp.
16 Heni Oktaviani - - Bidan - Hari 148.50 Rp.
17 Iis Istianah - - Bidan - Hari 156.83 Rp.
18 Tuti Rohati - - Bidan - Hari 156.83 Rp.
19 Iah Solihah - - bidan - Hari 156.83 Rp.
20 Marwati - - Bidan - Hari 165.17 Rp.
21 Fujiyati Sri. U. - - Bidan 1 Hari 115.13 Rp.
22 Eka Wulandari - - bidan - Hari 113.50 Rp.
23 Nuryanti - - Bidan 1 Hari 110.96 Rp.
24 Endang Istiqomah - - Bidan - Hari 113.50 Rp.
25 Siti Murni - - Bidan - Hari 109.33 Rp.
26 Yayah Marwiyah - - Bidan - Hari 109.33 Rp.
27 Vini Vuri Asih - - Bidan - Hari 109.33 Rp.
28 Sinta Ayu Dewi A.W. - - Bidan - Hari 109.33 Rp.
29 Ita Yutika - - Bidan - Hari 109.33 Rp.
30 Susila Sri Dewi.M. - - Bidan - Hari 113.50 Rp.
31 Vivi Nurluthfiah - - Bidan - Hari 109.33 Rp.
32 Iip Masripah - - Bidan - Hari 105.17 Rp.
33 Nurjanah - - Bidan - Hari 105.17 Rp.
34 Sudin - - Perawat - Hari 165.17 Rp.
35 Sri maela - - Perawat 2 Hari 120.92 Rp.
36 Evi Nurprihatin - - Perawat - Hari 109.33 Rp.
37 Yudhi Febriyanto - - Perawat - Hari 113.50 Rp.
38 Sari Sulistyowati - - Gizi - Hari 109.33 Rp.
39 Yuyun Purota`ayun - - Perawat 1 Hari 102.63 Rp.
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Tenaga Kesehatan dibawah D3

1 Edi Suprapto 19720514 200604 1 007 II Perawat - Hari 194.33 Rp.


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Tenaga Non Kesehatan dibawah D3

1 Subakti - - Administrasi Umum - Hari 121.83 Rp.


2 Sarka - - Administrasi Umum - Hari 176.00 Rp.
3 Tati Rohayati - - Administrasi Umum 1 Hari 143.59 Rp.
4 Julaekha - - Administrasi Umum - Hari 121.83 Rp.
5 Sri Rahayu - - Administrasi Umum - Hari 126.00 Rp.
6 Ani Yuliani - - Administrasi Umum 1 Hari 128.59 Rp.
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JUMLAH 9,063.32 Rp.

Bendahara Dana Kapitasi BPJS


FKTP Pada Puskesmas Kepuh

Ilawati
19750415 199503 2 002
an Jasa Pelayanan Kesehatan
S Pada FKTP Puskesmas Kepuh
an Oktober 2014

Besar Penerimaan Besar Uang


Pajak PNS/Non PNS NO. NPWP Tanda Tangan
Jasa Pelayanan Yg Diterima

2,045,624.71 Rp. 102,281.24 Rp. 1,943,343.47 14.301.503.0-426.000 1 .


1,472,427.01 Rp. 73,621.35 Rp. 1,398,805.66 70.665.611..3-426.000 2 .
1,411,448.53 Rp. 70,572.43 Rp. 1,340,876.10 45.973355.6-426.000 3 .
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1,537,470.72 Rp. 76,873.54 Rp. 1,460,597.18 57.595.596.8-426.000 1 .


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1,586,253.50 Rp. 79,312.68 Rp. 1,506,940.83 57.595.591.9-426.000 1 .


655,440.47 Rp. 32,772.02 Rp. 622,668.45 70.687.234.8-426.000 2 .
1,082,164.74 Rp. 0.00 Rp. 1,082,164.74 36.172.736.9.426.000 3 .
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987,851.36 Rp. 49,392.57 Rp. 938,458.79 57.595.585.1-426.000 1 .


1,167,534.61 Rp. 58,376.73 Rp. 1,109,157.88 57.595.587.7-426.000 2 .
1,143,143.22 Rp. 57,157.16 Rp. 1,085,986.06 57.595.588.5-426.000 3 .
1,204,121.70 Rp. 60,206.08 Rp. 1,143,915.61 57.595.589.3-426.000 4 .
1,220,007.38 Rp. 61,000.37 Rp. 1,159,007.01 57.595.590.1-426.000 5 .
703,285.13 Rp. 35,164.26 Rp. 668,120.87 58.084.292.0-426.000 6 .
1,012,868.17 Rp. 50,643.41 Rp. 962,224.76 57.595.597.6-426.000 7 .
968,150.62 Rp. 0.00 Rp. 968,150.62 67.719.260.1-426.000 8 .
1,004,925.33 Rp. 0.00 Rp. 1,004,925.33 67.719.260.1-426.000 9 .
1,203,934.07 Rp. 0.00 Rp. 1,203,934.07 57.595.593.5-426.000 10 .
964,273.02 Rp. 0.00 Rp. 964,273.02 36.375.191.8-426.000 11 .
980,533.94 Rp. 0.00 Rp. 980,533.94 57.595.601.6-426.000 12 .
980,533.94 Rp. 0.00 Rp. 980,533.94 57.595.602.4-426.000 13 .
826,055.13 Rp. 41,302.76 Rp. 784,752.37 36.793.962.6-426.001 14 .
785,402.81 Rp. 39,270.14 Rp. 746,132.67 24.906.386.8-426.001 15 .
724,424.33 Rp. 36,221.22 Rp. 688,203.11 36.548.056.5-426.000 16 .
765,076.65 Rp. 38,253.83 Rp. 726,822.82 36.186.328.5-426.000 17 .
765,076.65 Rp. 38,253.83 Rp. 726,822.82 55.386.126.1-426.000 18 .
765,076.65 Rp. 38,253.83 Rp. 726,822.82 36.186.328.5-426.000 19 .
805,728.97 Rp. 40,286.45 Rp. 765,442.52 34.492.897.3-426.001 20 .
561,627.43 Rp. 28,081.37 Rp. 533,546.06 70.670.070.5-438.000 21 .
553,684.59 Rp. 27,684.23 Rp. 526,000.36 70.675.520.4-426.000 22 .
541,301.27 Rp. 27,065.06 Rp. 514,236.20 25.730.504.5-426.001 23 .
553,684.59 Rp. 27,684.23 Rp. 526,000.36 70.675.383.7-426.000 24 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.652.675.3-426.000 25 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.676.882.7-426.000 26 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.657.963.8-426.000 27 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.651.797.6-426.000 28 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.688.828.6-426.000 29 .
553,684.59 Rp. 27,684.23 Rp. 526,000.36 70.675.632.7-426.000 30 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.675.578.2-426.000 31 .
513,032.27 Rp. 25,651.61 Rp. 487,380.66 70.684.419.8-426.000 32 .
513,032.27 Rp. 25,651.61 Rp. 487,380.66 70.651.485.8-426.000 33 .
805,728.97 Rp. 40,286.45 Rp. 765,442.52 16.954.415.2-426.000 34 .
589,896.43 Rp. 29,494.82 Rp. 560,401.60 64.296.125.4-426.999 35 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 70.675.469.4-426.000 36 .
553,684.59 Rp. 27,684.23 Rp. 526,000.36 55.280.566.5-426.000 37 .
533,358.43 Rp. 26,667.92 Rp. 506,690.51 68.486.424.3-401.000 38 .
500,648.95 Rp. 25,032.45 Rp. 475,616.50 66.011.400.0-426.000 39 .
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948,012.09 Rp. 0.00 Rp. 948,012.09 57.595.595.0-426.000 1 .


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594,336.91 Rp. 29,716.85 Rp. 564,620.06 16.954.416.0-426.000 1 .


858,576.99 Rp. 42,928.85 Rp. 815,648.14 16.954.418.6-426.000 2 .
700,470.73 Rp. 35,023.54 Rp. 665,447.20 16.954.414.5-426.000 3 .
594,336.91 Rp. 29,716.85 Rp. 564,620.06 16.954.423.7-426.000 4 .
614,663.07 Rp. 30,733.15 Rp. 583,929.92 70.680.171.9-426.000 5 .
627,296.56 Rp. 31,364.83 Rp. 595,931.73 16.954.417.8-426.000 6 .
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44,213,400.00 Rp. 1,804,043.61 Rp. 42,409,356.39

0.00 44,213,400.00
0.00 Kepuh Oktober 2014

Mengetahui,
Kepala FKTP Pada Puskesmas
Kepuh

dr. H. Edi Susanto


19780424 200604 1 017
Pajak Jasa Pelayanan Puskesmas Kepuh
Bulan Oktober 2014

No. Nama Terima Jaspel Golongan Pajak PNS Gol. III 5%, Gol II 0% NPWP
1 dr. H. Edi Susanto Rp 2,045,625 III Rp 102,281 14.301.503.0-426.000
2 Subhana, S.Kep.Ners. Rp 1,537,471 III Rp 76,874 57.595.596.8-426.000
3 Ilawati Rp 1,586,254 III Rp 79,313 57.595.591.9-426.000
4 Ngasiyah Rp 987,851 III Rp 49,393 57.595.585.1-426.000
5 Kurnaesih Rp 1,167,535 III Rp 58,377 57.595.587.7-426.000
6 Reni Ariyanti Rp 1,143,143 III Rp 57,157 57.595.588.5-426.000
7 Mohamad Ardi Rp 1,204,122 III Rp 60,206 57.595.589.3-426.000
8 Sri Sekarkuningsih Rp 1,220,007 III Rp 61,000 57.595.590.1-426.000
9 Supiah Rp 703,285 III Rp 35,164 58.084.292.0-426.000
10 Neneng Susanah Rp 1,012,868 III Rp 50,643 57.595.597.6-426.000
11 Carminah Rp 968,151 II 67.719.260.1-426.000
12 Sri Eviyani Rp 1,004,925 II 67.719.260.1-426.000
13 Yuly Tresnawiati Rp 1,203,934 II 57.595.593.5-426.000
14 Anisa Nurzanah Rp 964,273 II 36.375.191.8-426.000
15 Nani Juniarti Rp 980,534 II 57.595.601.6-426.000
16 Eep Repiyanti Rp 980,534 II 57.595.602.4-426.000
17 Edi Suprapto Rp 948,012 II 57.595.595.0-426.000
18 Dewi Nur Sobariyah Rp 1,082,165 II 36.172.736.9.426.000
JML Rp 20,740,688 Rp 630,408.02

No. Nama Terima Jaspel Non PNS Pajak Non PNS 5% NPWP
1 dr. Feronila Pardede Rp 1,472,427 PTT Rp 73,621 70.665.611..3-426.000
2 dr. Siti Kodija Rp 1,411,449 PTT Rp 70,572 45.973355.6-426.000
3 Darmini Rp 826,055 PTT Rp 41,303 36.793.962.6-426.001
4 Lilis Komalasari Rp 785,403 PTT Rp 39,270 24.906.386.8-426.001
5 Heni Oktaviani Rp 724,424 PTT Rp 36,221 36.548.056.5-426.000
6 Iis Istianah Rp 765,077 PTT Rp 38,254 36.186.328.5-426.000
7 Tuti Rohati Rp 765,077 PTT Rp 38,254 55.386.126.1-426.000
8 Iah Solihah Rp 765,077 PTT Rp 38,254 36.186.328.5-426.000
9 Marwati Rp 805,729 PTT Rp 40,286 34.492.897.3-426.001
10 Fujiyati Sri. U. Rp 561,627 Honorer Rp 28,081 70.670.070.5-438.000
11 Eka Wulandari Rp 553,685 Honorer Rp 27,684 70.675.520.4-426.000
12 Nuryanti Rp 541,301 Honorer Rp 27,065 25.730.504.5-426.001
13 Endang Istiqomah Rp 553,685 Honorer Rp 27,684 70.675.383.7-426.000
14 Siti Murni Rp 533,358 Honorer Rp 26,668 70.652.675.3-426.000
15 Yayah Marwiyah Rp 533,358 Honorer Rp 26,668 70.676.882.7-426.000
16 Vini Vuri Asih Rp 533,358 Honorer Rp 26,668 70.657.963.8-426.000
17 Sinta Ayu Dewi A.W. Rp 533,358 Honorer Rp 26,668 70.651.797.6-426.000
18 Ita Yutika Rp 533,358 Honorer Rp 26,668 70.688.828.6-426.000
19 Susila Sri Dewi.M. Rp 553,685 Honorer Rp 27,684 70.675.632.7-426.000
20 Vivi Nurluthfiah Rp 533,358 Honorer Rp 26,668 70.675.578.2-426.000
21 Iip Masripah Rp 513,032 Honorer Rp 25,652 70.684.419.8-426.000
22 Nurjanah Rp 513,032 Honorer Rp 25,652 70.651.485.8-426.000
23 Sudin Rp 805,729 TKK Rp 40,286 16.954.415.2-426.000
24 Sri maela Rp 589,896 Honorer Rp 29,495 64.296.125.4-426.999
25 Evi Nurprihatin Rp 533,358 Honorer Rp 26,668 70.675.469.4-426.000
No. Nama Terima Jaspel Golongan Pajak PNS Gol. III 5%, Gol II 0% NPWP

26 Yudhi Febriyanto Rp 553,685 Honorer Rp 27,684 55.280.566.5-426.000


27 Sari Sulistyowati Rp 533,358 Honorer Rp 26,668 68.486.424.3-401.000
28 Yuyun Purota`ayun Rp 500,649 Honorer Rp 25,032 66.011.400.0-426.000
29 Subakti Rp 594,337 Honorer Rp 29,717 16.954.416.0-426.000
30 Sarka Rp 858,577 Honorer Rp 42,929 16.954.418.6-426.000
31 Tati Rohayati Rp 700,471 TKK Rp 35,024 16.954.414.5-426.000
32 Julaekha Rp 594,337 Honorer Rp 29,717 16.954.423.7-426.000
33 Sri Rahayu Rp 614,663 Honorer Rp 30,733 70.680.171.9-426.000
34 Ani Yuliani Rp 627,297 Honorer Rp 31,365 16.954.417.8-426.000
35 Wandi Furqoni Rp 655,440 Honorer Rp 32,772 70.687.234.8-426.000
Jml Rp 23,472,712 Rp 1,173,635.59

Rp 1,804,043.61
JML Pajak

Rp 1,804,044

Rp 1,804,044