DINAS KESEHATAN K A B U P A T E N T A S I K M A L A Y A

UPTD PUSKESMAS SODONGHILIR

Jalan Raya Timur No.18 Sodonghilir Tlp ( 0265) 7084173

SURAT TUGAS
NO.005 /....... / PKM / 2016

Kepala UPTD Puskesmas Sodonghilir Kabupaten Tasikmalaya, dengan ini menugaskan kepada :

Nama : Rano Nurcipta, Amd.Kep

NIP : 19830217 201410 1 001
Pangkat / Golongan : Pengatur / IIc
Untuk melaksanakan : Pertemuan Evaluasi BPB dan Sosialisasi MPASI
Selama : 1 ( Satu ) hari
Tanggal : 17 Oktober 2016
Tempat yang dikunjungi : Aula Dinas Kesehatan Kabupaten Tasikmalaya

Demikian surat tugas ini dibuat untuk dilaksanakan dengan penuh rasa tanggungjawab.

Tasikmalaya, 17 Oktober 2016

Kepala UPTD Puskesmas Sodonghilir

MOH. DAUD SAPUTRA, SIP.,MMKes

NIP. 19610825 198308 1 002
KETERANGAN
SPPD NO. :
Berangkat dari : UPTD Puskesmas Sodonghilir
(Tempat Kedudukan)
PADA TANGGAL : 17 Oktober 2016
PEJABAT PELAKSANA TEKNIS KEGIATAN

Dodoy Suherman, SIP

NIP. 19610606 198603 1 019
I. Tiba di : Aula DKK Kab. Taskmalaya Berangkat dari : Aula DKK Kab. Taskmalaya
Pada tanggal : 17 Oktober 2016 Ke : UPTD Puskesmas Sodonghilir
Kepala : Pada tanggal : 17 Oktober 2016
Kepala :

(........................... ..................................................) (........................... ..................................................)

NIP. NIP.
II. Tiba di : Berangkat dari :
Pada tanggal : Ke :
Kepala : Pada tanggal :
Kepala :

III. Tiba di : Berangkat dari :

Pada tanggal : Ke :
Kepala : Pada tanggal :
Kepala :

IV. Tiba Kembali di (tempat kedudukan)

Pada Tanggal : 17 Oktober 2016
Telah diperiksa dengan keterangan bahwa perjalanan tersebut
diatas benar dilakukan atas perintahnya dan semata-mata untuk
kepentingan jabatan dalam waktu yang sesingkat-singkatnya

Pejabat yang memberi perintah

KEPALA DINAS KESEHATAN
KABUPATEN TASIKMALAYA

H. Oki Zulkifli Duski, dr, M.Epid

NIP. 19581016 198911 1 002

CATATAN LAIN-LAIN

PERHATIAN :
Pejabat yang berwenang menerbitkan SPPD, pegawai yang melakukan perjalanan dinas, para
pejabat yang mengesahkan tanggal berangkatnya/tiba serta bendaharawan bertanggungjawab
berdasarkan peraturan-peraturan keuangan Negara, apabila Negara menderita rugi akibat
kesalahan kelalaian dan kealpaannya.
 PEMERINTAH KABUPATEN TASIKMALAYA
DINAS KESEHATAN
Komplek Perkantoran Setda Kabupaten Tasikmalaya
Jl. Bojongkoneng-By Pass Tlp. (0265) 2553153 (Fax)-2553155-2553157
Desa Sukaasih Kecamatan Singaparna Kabupaten Tasikmalaya

Lembar Ke : ………………
Kode No : ………………
Nomor : ………………

SURAT PERINTAH PERJALANAN DINAS ( S.P.P.D )

1 Pejabat berwenang yang memberi perintah Kepala Dinas Kesehatan Kabupaten Tasikmalaya

Rano Nurcipta Amd.Kep

2 Nama pegawai yang diperintah
NIP. 19830217 201410 1 001
a. Pangkat dan golongan ruang gaji
3 a. Pengatur II c
menurut PP No. 6 tahun 1997

b. Jabatan / Instansi b. Tenaga Pelaksana Gizi / UPTD Puskesmas Sodonghilir

c. Tingkat menurut peraturan

c.
perjalanan dinas
4 Maksud perjalanan dinas Pertemuan Evaluasi BPB dan Sosialisasi MPASI

5 Alat angkutan yang dipergunakan Umum

6 a. Tempat berangkat a. UPTD Puskesmas Sodonghilir

b. Aula DKK Tasikmalaya
b. Tempat tujuan

7 a. Lama perjalanan dinas a. 1 (satu) hari

b. Tanggal berangkat b. 17 Oktober 2016
c. Tanggal harus kembali c. 17 Oktober 2016
8 Pengikut : Nama Tanggal Lahir Keterangan
1. ………………………………………

9 Pembebanan anggaran
a. Instansi a. Dinas Kesehatan Kabupaten Tasikmalaya
b. Mata Anggaran b. 5221501
10 Keterangan lain

Dikeluarkan di : KAB. TASIKMALAYA

Pada Tanggal : 17 Oktober 2016
Kepala Dinas Kesehatan
Kabupaten Tasikmalaya

H. Oki Zulkifli Duski, dr, M.Epid

NIP. 19581016 198911 1 002
 LAPORAN HASIL KEGIATAN

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