PEMERINTAH KABUPATEN JOMBANG

DINAS KESEHATAN
UPTD PUSKESMAS PLANDAAN
JL. Bangsri-Gebang No. 09 Plandaan. Kode Pos : 61456
Telp. (0321) 887028 Email : pkmplandaan@gmail.com

BERITA ACARA PENILAIAN KEWENANGAN KLINIS

Pada hari ini ...................., ......... ( ......................................) ......................20.....( ..............................)

Pukul ................WIB, bertempat di .................................UPTD Puskesmas Plandaan, telah
dilakukan kredensial oleh tim kredensial UPTD Puskesmas Plandaan yang dihadiri oleh anggota tim
kredensial dan koordinator ..............................., atas staf layanan klinis,
Nama : ..................................................................................................
Tempat / Tanggal Lahir : ..................................................................................................
Pendidikan Terakhir : ..................................................................................................
Jenis Ketenagaan : ..................................................................................................
Alamat : ..................................................................................................
Dengan kesimpulan sebagai berikut :
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Jombang, ........................

Tim Kredensial
Ketua Sekertaris

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

Penilai

1. Koordinator Perawat / Bidan :

(............................................)
2. Koordinator UGD, Rawat
Inap/BP.Umum/Ruang Bersalin:

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