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PEMERINTAH KABUPATEN TEBO

DINAS KESEHATAN
UPTD PUSKESMAS SUMBER SARI
Jl.JayapuraDesaSumber SariKec.RimboUluKab.Tebo 37253

LAPORAN PERJALANAN DINAS


1. Dasar : Surat Tugas No. 090 / /SPT/20

2. Tujuan Kunjungan/Rapat :

3. Hasil Kunjungan/Rapat :

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4. Kesimpulan / Sarana Perbaikan : .......................................................................................................


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tgl………………………………………………
Pelapor
Mengetahui
Petugas / Warga wilayah yang di kunjungi
Cap / Stempel (Jika Ada) 1. 1. ………………………

2. 2. ………………………

3. 3. ………………………

4. 4. ………………………

5. 5. ………………………

6. 6. ………………………

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