Stase : ..........................................................................................
Nama Preceptee : ..........................................................................................
Nama Prceptor Klinik : ..........................................................................................
Nama Preceptor Akademik : ..........................................................................................
Periode Waktu : ..........................................................................................
Ruang / Rumah Sakit :
Mengetahui
Malang, ___________________
Preseptor Akademik Preseptor Klinik Preceptee