VVVVVV

SKP 1 1 %e!ulas 7an! men!
atu( pela&sanaan dent'&as pasen SK, Pedoman/Panduan, SPO

)%*
2 Ident'&as pasen dla&u&an den!an men!!una&an mn 2 Implementas dan !elan! pasen
denttas dan tda& 4ole men!!una&an nomo( &ama( atau
lo&as pasen d(a8at sesua den!an (e!ulas %S )D,O,-*
" Ident'&as pasen dla&u&an se4elum tnda&an,p(osedu( Implementas

D9, dan te(apeut& )-,O,S*
# Ident'&as pasen se4elum pem4e(an o4at, da(a, p(odu& Implementas
da(a, pen!am4lan spesmen, dan pem4e(an det )-,O,S*
)-,O,S*
$ dent'&as pasen se4elum (adote(ap, mene(ma a(an IV, Implementas

emodalss, pen!am4lan da(a atau pen!am4lan
spesmen lan ut& peme(&saan &lns, &ate(sas antun!,
p(osedu( (adolo! d0 dan dent'&as pasen &oma )-,O,S*
SKP 2 1 %e
% e!ulas tt! &omun&as e'e&t' anta( PPA ) % * SK, Pedoman/Panduan, SPO
2 +u&t pelatan &omun&as e'e&t' anta( PPA )D,-* TO% D&lat . se(t'&at S+A%
" Pesan 6e(4al/6e(4al le8at telepon dtuls len!&ap, d4aa TTD ap &on'(mas 102# am dalam PPT
ulan! ole pene(ma pesan dan d&on'(mas ole pem4e(
pesan )D,-,S*
SKP 231 1 %S menetap&an 4esa(an nla &(ts asl peme(&saan SK, Pedoman/Panduan, SPO
da!nost& dan asl da!nost& &(ts ) % *
2 %S menetap&an sapa 7an! a(us melapo(&an dan sapa +u&u lapo(an nla &(ts la4 . %adolo!
7an! mene(ma nla &(ts asl peme(&saan d0 dan datat
dlm %M )-,S*
SKP 232 1 +u&t atatan tentan! al:al &(t&al d&omun&as&an d 5o(mul( se(a te(ma pasen
anta(a PPA pada 8a&tu dla&u&an se(a te(ma pasen
);andO6e(* )D,-*
2 'o(mul(, alat dan metode dtetap&an untu& mendu&un! TTD 6e('&as d 'o(mul( se(a te(ma pasen
p(oses se(a te(ma pasen 4la mun!&n mel4at&an pasen
)D,-*
" +u&t dla&u&an e6aluas atatan &omun&as 7an! te(ad TTD 6e('&as d 'o(mul( se(a te(ma pasen
8a&tu se(a te(ma pasen ut& mempe(4a& p(oses )D,-*
SKP " 1 %e!ulas tt! pen7edaan, pen7mpanan, penataan, SK, Pedoman/Panduan, SPO
pen7apan, dan pen!!unaan o4at 7! pe(lu d8aspada ) % *
2 %S men! mp
mplementas&an (e!ulas 7! tela d4uat )D,-* +u&u lapo(an sto& ;A
" d %S te(seda da'ta( semua o4at 7! pe(lu d 8aspada 7! lst o4at ;A tap unt
dsusun 4e(dasa( atas data spes'& sesua den!an (e!ulas
)D,O,-*
# Tempat pen7mpanan, pela4elan, dan pen7mpan o4at 7! +u&u lapo(an o4at, t(ole7 eme(!en7 < Lst
pe(lu d8aspada te(masu& o4at NO%UM datu( d tempat
aman )D,O,-*
SKP "31 1 %e!ulas ut& mela&sana&an p(oses mene!a &e&u(an! SK, Pedoman/Panduan, SPO
at:atan dlm men!elola ele&t(olt &onsent(at ) % *
2 ele&t(olt &onsent(at an7a te(seda d unt &e(a / nstalas +u&u Lapo(an a(an ele&t(olt &onsent(at
'a(mas atau depo 'a(mas )D,O,-*
SKP # 1 %e!ulas mela&sana&an penandaan lo&as ope(as atau SK, Pedoman/Panduan, SPO
tnda&an n6as' )ste ma(&n!* ) % *
2 4u&t %S men!!una&an 1 tanda d tempat sa7atan ope(as 5o(mul( ste ma(&n!
atau tnda&an n6as' 7! se!e(a dpt d&enal d!n epat
sesua d!n &e4a&an dan p(osedu( %S )D,O*
" 4u&t penandaanlo&as ope(as/tnda&an n6as' dla&u&an TTD DP=P, Pasen dan Sa&s dlm 'o(mul( ste
ole sta' meds 7! mela&u&an ope(as atau tnda&an n6as' ma(&n!
d!n mel4at&an pasen )D,O,-*
SKP #31 1 %e!ulas ut& p(osedu( 4eda aman d!n men!!una&an SK, Pedoman/Panduan, SPO
SS da( -;O ) % *
2 Se4elum ope(as/tnda&an n6as' dla&u&an, %S e&lst Su(!al Sa'et7 Lst
men7eda&an e&lst/p(oses
e&lst/p(oses lan ut& menatat, apa&a I
sd 4ena(, len!&ap, Tepat:lo&as/p(osedu(/pasen,
do&umen/pe(alatan
do&umen/pe(alatan sd sap te(seda d!n len!&ap dan
4e('un!s 4a& )D,O*
" %S men!!una&an &omponen tme:out te(d( atas e&lst Su(!al Sa'et7 Lst
dent'&as tepat:pasen/p(osedu(/lo
tepat:pasen/p(osedu(/lo&as,
&as, pe(setuuan
tnda&an dan &on'(mas 4a8a p(oses 6e('&as sd
len!&ap dla&u&an se4elum (san )D,O,-,S*
# %S men!!una&an &etentuan 7! sama tt! tepat: 5o(mul( I
lo&as/p(osedu(/pasen
lo&as/p(osedu(/pasen &a ope(as dla&u&an dlua( &ama(
ope(as te(masu& p(osedu( tnda&an meds dan !!
)D,O,-*
SKP $ 1 %e!ulas tt! pedoman &e4e(san tan!an 7! men!au SK, Pedoman/Panduan, SPO
pada standa( -;O te(&n ) % *
2 %S mela&sana&an p(o!(am &e4e(san tan!an d selu(u TO% Sosalsas
%S sesua d!n (e!ulas
" Sta' %S dpt mela&u&an u tan!an sesua d!n p(osedu( Implementas
)-,O,S*
# +u&t sta' mela&sana&an $ moment u tan!an3 $ apa? Implementas
)-,O,S*
$ P(osedu( dsn'e&s d %S dla&u&an sesua d!n (e!ulas spll &t
)-,O,S*
> +u&t %S mela&sana&an e6aluas te(adap upa7a Data Analss PPI
menu(un&an an!&a n'e&s te(&at pela7anan &eseatan
)D,-*
SKP > 1 %e!ulas 7! men!atu( tt! mene!a pasen de(a &a(ena SK, Pedoman/Panduan, SPO
atu ) % *
2 %S mela&sana&an suatu p(oses assesmen te(adap 5o(mul( ass (es&o atu
semua ps (anap dan (aal d!n &onds, da!noss dan lo&as
te(nd&as 4e(s&o atu tn!! sesua d!n (e!ulas )D,O,-*
" %S mela&sana&an p(oses ass a8al, lanutan, ulan! da( ps 'o(mul( (e:assesment (es&o atu
(anap 4e(dasa( atas atatan te(dent'&as (s&o atu
)D,O,-*
# Lan!&a2 dada&an ut& men!u(an! (s&o atu 4a! pasen 'o(mul( nte(6ens dlm 'o(m (es&o atu
da( stuas dan lo&as 7! men7e4a4&an pasen atu
)D,O,-*
STD NO ELEMEN PENILAIAN Y/T DOKUMEN EVALUASI
1 %e!ulas ut& p(oses s&(nnn! 4a& ddalam maupun SK, Pedoman/panduan, SPO
dlua( %S te(masu& peme(&saan penunan! 7!
dpe(lu&an/spes'& ut& menetap&an ps dte(ma/d(uu&
)%*
2 pela&sanaan p(oses s&(nnn! 4a& ddalam maupun d 'o(mul( s(ennn!
lua( %S )D,-*
" p(oses peme(&saan penunan! 7! dpe(lu&an/spes'& asl peme(&saan la4
untu& menetap&an apa&a ps dte(ma/d(uu&
A%K 1
# +e(dasa(&an asl s&(nn! dtentu&an apa&a 'o(mul( s(eenn!

&e4utuan ps sesua d!n &emampuan %S )D,-*
$ PS dte(ma 4la %S dpt mem4e( pela7anan (aal dan 'o(mul( s(eenn!
(anap 7an! d4utu&an ps )D,O,-*
> Ps tda& d(a8at, tda& dpnda&an/d(uu& se4elum 'o(mul( s(eenn!
dpe(ole asl test 7! d4utu&an te(sedan )D,O,-*
1 %e!ulas tt! p(oses t(ase 4e(4ass 4u&t ) % * SK, Pedoman/panduan, SPO

2 pela&sanaan pen!!unaan p(oses t(ase 4e(4ass 4u&t 5o(mul( T(ase dlm 'o(m ass a8al ps
7! dpe(!una&an ut& memp(o(tas&an ps sesua d!n
&e!a8atann7a )D,-*
A%K 131 " sta' sd te(lat men!!una&an &(te(a )D,-,S* TO% sosalsas T(ase
# pasen d!n &e4utuan mendesa& dp(o(tas&an 5o(mul( T(ase dlm 'o(m ass a8al ps
)D,-,S*
$ &onds pasen dsta4l&an se4elum d t(ans'e(/ d(uu& 5o(m ass a8al pasen
dan ddo&umentas&an )D,-,S*
1 %e!ulas tt! s&(nn! ps masu& (anap ut& menetap&an SK, Pedoman/panduan, SPO
&e4utuan pela7anan p(e6ent', palat', &u(at' dan
(ea4ltat' ) % *
2 pela&sanaan s&(nn! ps masu& (anap ut& 'o(mul( s(eenn!
menetap&an &e4utuan pela7anan p(e6ent', palat',
A%K 132 &u(at' dan (ea4ltat' )D,-*
" temuan dp(oses s&(nn! menentu&an pela7anan atau 'o(mul( s(eenn!
tnda&an &epada ps )D,O,-*
# P(o(tas d4e(&an pd pela7anan te(&at p(e6ent', 'o(mul( s(eenn!
palat', &u(at' dan (ea4ltat'
1 (e!ulas penundaan dan &elam4atan pela7anan d SK, Pedoman/panduan, SPO
(aal maupun (anap 7! (s dsampa&an &epada ps ) %
*
A%K 13" 2 Ps d4e(tau alasan penundaan dan &elam4atan 5o(m edu&as
pela7anan dan d4e( n'o(mas tt! alte(nat' 7!
te(seda sesua &e4utuan &ln& ps dan d atat dlm
%M )D,-*
1 (e!ulas tt! p(oses penda'ta(an ps (aal, (anap, I@D, SK, Pedoman/panduan, SPO
pene(maan ps !8at da(u(at &e unt (anap, menaan
ps ut& do4se(6as dan men!elola ps 4la td& te(seda
tmpt tdu( pd unt 7! dtuu maupun d selu(u %S ) % *
2 Pela&sanaan p(oses pene(maan pasen (anap dan 5o(mul( Komun&as

penda'ta(an %aal )D,-*
" pela&sanaan p(oses pene(maan ps !a8at da(u(at &e 'o(mul( pe(mntaan %anap
unt (a8at nap )D,-*
A%K 2
# Pela&sanaan p(oses menaan pasen ut& d o4se(6as 'o(mul( o4se(6as
)D,-*
$ Pela&sanaan p(oses men!elola ps 4la td& te(seda 'o(mul( (uu&an
tempat tdu( pd unt 7! dtuu maupun d selu(u %S
)D,-*
> sta' memaam dan mela&sana&an semua p(oses TO% Sosalsas Alu( Pasen
sesua (e!ulas )D,-*
 Pela&sanaan sstem penda'ta(an (aal dan (anap I;A Mo4le
sea(a onlne )D,-*
1 Penelasan te(masu& (enana asuan d 'o(mul( edu&as
do&umentas&an )D,-*
2 Penelasan te(masu& asl asuan 7! da(ap&an dan 'o(mul( edu&as
ddo&umentas&an )D,-*
A%K 231
" Penelasan te(masu& pe(&(aan 4a7a 7! dtan!!un! 'o(mul( edu&as
ps atau &elua(!a )D,-*
# penelasan 7! d4e(&an dpaam ole ps . &elua(!a Implementas
7! mem4uat &eputusan )-*
1 %e!ulas 7! mne!atu( tt! p(oses ut& men!atu( alu( SK, Pedoman/panduan, SPO
pasen d %S te(masu& elemen a* s/d !* d ma&sud
dan tuuan ) % *
2 Pela&sanaan Pen!atu(an alu( ps ut& men!nda( 'lo8a(t alu( pasen, St(u& ant(an ps
A%K 232
penumpu&an )D,-*
" Dla&u&an e6aluas te(adap pen!atu(an alu( ps lapo(an/asl audt
sea(a 4e(&ala dan mela&sana&an upa7a
pe(4a&ann7a )D,O,-*
1 %e!ulas tt! &(te(a masu& dan &elua( IU, unt SK, Pedoman/panduan, SPO ;U ??
spesalst& lan, (uan! pe(a8atan palat' te(masu&
4la d!una&an ut& (set/p(o!(am lan ut& memenu
&e4utuan ps 4e(dasa( atas &(te(a p(o(tas, d0,
pa(amete( o4e&t', se(ta &(te(a 4e(4ass 'solo! dan
&ualtas dup ) % *
A%K 23" 2 Sta' 7! &ompeten dan 4e(8enan! da( unt 'o(m s(eenn! pela7anan spesalst&
ntens'/unt spesalst& te(l4at dlm menentu&an
&(te(a )D,-*
" sta' te(lat ut& mela&sana&an &(te(a )D,-* aBa/se(t'&at
# atatan meds ps 7! dte(ma masu&/&elua( da( unt PPT
ntens' atau unt spesalst& memuat 4u&t 4a8a ps
memenu &(te(a masu&/&elua( )D,-*
1 %S menetap&an p(oses pen7usunan pe(enanaan SK, Pedoman/panduan, SPO
pemulan!an ps dmula pd ass a8al (anap ) % *
2 %S menetap&an &(te(a ps 7! mem4utu&an P" 'o(m dsa(!e plannn!
A%K "
)%,D,O,-*
" P(oses P" dan pela&sanaann7a datat d dlm %M 'o(m dsa(!e plannn!
sesua (e!ulas %S )D*
1 %e!ulas tt! p(oses dan pela&sanaan ut& mendu&un! SK, Pedoman/panduan, SPO
&esnam4un!an dan &oo(dnas asuan, te(masu&
paln! sed&t  s/d I 7! dmuat d ma&sud dan tuuan
sesua (e!ulas %S ) % *
2 penunu&&an MPP d!n u(aan tu!as anta(a lan dlm %KK dan U(aan Tu!as MPP
&onte&s mena!a &esnam4un!an dan &oo(dnas
pela7anan 4a! nd6du ps melalu &omun&as dan
&e(asama d!n PPA dan pmpnan unt se(ta
mena&up 4ut( a* s/d * d ma&sud dan tuuan )D,-*
A%K "31 " pasen ds(eenn! ut& &e4utuan pela7anan MPP 'o(mul( MPP
)D,-*
# ps 7! mendapat pela7anan MPP, penatatann7a SOP dan 'o(m MPP
dla&u&an dlm 'o(m MPP selalu dpe(4aa(u ut&
menamn &omun&as den!an PPA )%,D*
$ &esnam4un!an dan &oo(dnas p(oses pela7anan 'o(m (enana asuan PPA
ddu&un! d!n men!!una&an pe(an!&at pendu&un!
sepe(t (enana asuan PPA, atatan MPP, Panduan
atau pe(an!&at lann7a )D,O,-*
> &esnam4un!an dan &oo(dnas dpt d4u&t&an d TTD 6e('&as te(nte!(as
semua tn!&at/'ase asuan pasen )D,O,-*
1 (e!ulas tt! DP=P mela&u&an &oo(dnas asuan dan SK, Pedoman/panduan, SPO
4e(tu!as dlm selu(u 'ase asuan (anap ps se(ta
te(dent'&as dlm %M ps ) % *
2 %e!ulas u!a menetap&an p(oses pen!atu(an SK, Pedoman/panduan, SPO
pe(pndaan tan!!un! 84 &oo(dnas asuan ps da(
1 DP=P &e DP=P lan, te(masu& 4la te(ad pe(u4aan
A%K "32 DP=P utama ) % *
" DP=P 7! dtetap&an tela memenu p(oses Su(at &(edensal do&te(
&(edensal 7! sesua d!n pe(atu(an pe(undan!an
)D,-*
# +la dla&sana&an (a4e( dtetap&an DP=P utama 5o(mul( Konsul
se4a!a &oo(dnato( asuan ps )D,-*
1 %e!ulas tt! t(ans'e( ps anta( unt pela7anan d dlm SK, Pedoman/panduan, SPO
%S dlen!&ap d!n 'o(m t(ans'e( ps ) % *
2 5o(m ts4 memuat nd&as ps masu& d(a8at )D* 'o(m pe(pndaan pasen
" 5o(m ts4 memuat %8a7at &eseatan, P5, dan 'o(m pe(pndaan pasen
Pem3Da!nost& )D*
# 5o(m ts4 memuat setap d0 7! d4uat )D* 'o(m pe(pndaan pasen
A%K "3"
$ 5o(m ts4 memuat setap p(osedu( 7! dla&u&an )D* 'o(m pe(pndaan pasen
> 5o(m ts4 memuat o4at 7! d4e(&an dan tnda&an lan 'o(m pe(pndaan pasen
7! dla&u&an )D*
 5o(m ts4 memuat&eadaan ps pada 8a&tu dpnda 'o(m pe(pndaan pasen
)D*
C &etentuan ts4 dla&sana&an )D,O,-* 'o(m pe(pndaan pasen
1 %e!ulas tt! pemulan!an ps dse(ta &(te(a SK, Pedoman/panduan, SPO
pemulan!an ps dan ps 7! (enana pemulan!ann7a
&omple&s ut& &esnam4un!an asuan sesua d!n
&onds &eseatan dan &e4utuan pela7anan ps ) % *
2 4u&t pemulan!an pasen sesua d!n &(te(a 'o(m dsa(!e plannn!

A%K # pemulan!an ps )D,-*
" (e!ulas 7! menetap&an &(tte(a ps 7! dn&an untu& SK, Pedoman/panduan, SPO
&elua( menn!!al&an %S selama pe(ode te(tentu
)%*
# 4u&t pela&sanaan tt! ps 7! dBn&an ut& &elua( 'o(mul( menn!!al&an %S
menn!!al&an %S selama pe(ode 8a&tu te(tentu
)D,-*
1 4u&t pemulan!an asuan 7! (enana pemulan!ann7a 'o(m dsa(!e plannn!
&omple&s dmula sea& a8al ps masu& (anap
mel4at&an semua PPA te(&at se(ta d'asltas ole
MPP, ut& &esnam4un!an asuan sesua d!n &onds
&eseatan dan &e4utuan pela7anan ps )D,-*
A%K #31
2 pada tnda& lanut pemulan!an ps 4la dpe(lu&an dpt (uu&an &omuntas/'asltas
dtuu&an &epada 'asltas &eseatan 4a& pe(o(an!an
ataupun nsttus 7! 4e(ada d&omuntas dmn ps
4e(ada 7! 4e(tuuan ut& mem4e(&an 4antuan
pela7anan )D*
1 (n!&asan pulan! memuat (8a7at &eseatan, P5, dan (esume pulan!

Pem3D0 )D*
2 (n!&asan pulan! memuat nd&as ps d (anap, d0, (esume pulan!
dan &omo(4dtas lan )D*
" (n!&asan pulan! memuat p(osedu( te(ap dan (esume pulan!
tnda&an 7! tela d&e(a&an )D*
A%K #32
# (n!&asan pulan! memuat o4at 7! d4e(&an te(masu& (esume pulan!
o4at setela ps &elua( %S )D*
$ (n!&asan pulan! memuat &onds &eseatan ps daat (esume pulan!
a&an pl! da( %S )D*
> (n!&asan pulan! memuat nst(u&s tnda& lanut dan (esume pulan!
delas&an &epada ps dan &elua(!a )D*
1 %n!&asan pl! d4uat ole DP=P se4elum ps pulan! (esume pulan! < TTD DP=P
)D,-*
2 Satu salnan (n!&asan d4e(&an &epada ps dan 4la (esume pulan! < TTD DP=P
dpe(lu&an dpt dse(a&an &epada tena!a &eseatan
7! 4e(tan!!un! a8a4 mem4e(&an &elanutan asuan
A%K #3231 )D,-*
" satu salnan (n!&asan 7! len!&ap dtempat&an d %M (esume pulan! < TTD DP=P
)D*
# satu salnan (n!&asan d4e(&an &epada pa& (esume pulan! < TTD DP=P
penamn sesua d!n (e!ulas %S )D*
1 Dtetap&an &(te(a ps (aal d!n asuan 7! &omple&s SK, Pedoman/panduan, SPO
atau da!nossn7a &omple&s dpe(lu&an P%M%= 7!
sesua d!n (e!ulas %S ) % *
2 %e!ulas 7! menetap&an 4a8a p(oses P%M%= SK, Pedoman/panduan, SPO
muda dtelusu( dan muda d (e6e8 ) % *
A%K #3"
" In'o(mas pentn! 7! dmasu&&an &e dlm P%M%= SK, Pedoman/panduan, SPO
ddent'&as&an oel DP=P )%,D*
# P(oses ts4 d e6aluas ut& memenu &e4utuan pa(a (apat e6aluas
DP=P dan menn!&atan mutu se(ta &eselamatan ps
)D,-*
1 %e!ulas ut& men!elola ps (aal dan (anap 7! menola& SK, Pedoman/panduan, SPO
(enana asuan meds te(masu& &elua( %S atas
pe(mntaan send( dan ps 7! men!enda&
pen!entan pen!o4atan ) % *
2 4u&t pem4e(an edu&as &epada ps tt! (es&o meds 'o(m edu&as
a&4at asuan meds 7! 4elum len!&ap )D,O,-*
" ps &elua( %S atas pe(mntaan send(, tetap ttp 'o(m pulpa&

A%K #3#
men!&ut p(oses pemulan!an ps )D*
# Do&te( &elua(!a )4la ada* atau do&te( pem4e( (esume pulan!
asuan 4e(&utn7a da( ps d4e(tau tt! &onds ts4
)D*
$ do&umentas %S mela&u&an pen!&aan ut& 'o(m pulpa&
men!etau alasan ps &elua( %S atas apa&a
pe(mntaan send(, menola& asuan meds atau tda&
melanut&an p(o!(am pen!o4atan )D*
1 (e!ulas 7! men!atu( ps (anap dan (aal 7! SK, Pedoman/panduan, SPO
menn!!al&an (s tanpa pem4e(tauan )mela(&an d(*
)%*
2 %S mela&u&an dent'&as ps mende(ta pen7a&t 7! 'o(m dent'&as
A%K #3#31 mem4aa7a&an d(n7a send( atau ln!&un!an )D,-*
" %S melapo(&an &epada pa& 7! 4e(8enan! 4la ada

nd&as &onds ps 7! mem4aa7a&an d(n7a send(
atau ln!&un!an )D,-*
1 %e!ulas tt! (uu&an sesua d!n pe(atu(an pe(undan!: SK, Pedoman/panduan, SPO
undan!an ) % *
2 (uu&an pasen dla&ua&n sesua d!n &e4utuan 'o(m (uu&an
&esnam4un!an asuan pasen )D*
A%K $ " %S 7an! me(uu& memast&an 4a8a 'asltas 'o(m (uu&an
&eseatan 7! mene(ma dpt memenu &e4utuan ps
7! d(uu& )D,-*
# &e(asama %S 7an! me(uu& d!n %S 7an! mene(ma mou, SPO
(uu&an 77! se(n! d(uu& ) % *
1 sta' 7! 4e(tan!!un! 84 dlm pen!elolaan (uu&an 'o(m (uu&an
te(masu& ut& memast&an ps dte(ma d %S (uu&an
7! dpt memenu &e4utuan ps )D,-*
2 Selama p(oses (uu&an ada sta' 7! &ompeten sesua 'o(m monto(n! am4ulane
d!n &onds ps 7! selalu memonto( dan menatatn7a
dlm %M )D,-*
A%K $31 " selama p(oses (uu&an te(seda o4at, 4aan meds
a4s pa&a, al&es, dan pe(alatan meds sesua d!n
&e4utuan &onds ps )D,O,-*
# P(oses se(a te(ma ps anta( sta' pen!anta( dan 7! TTD 6e('&as 'o(m (uu&an
mene(ma )D,O,-*
$ Ps dan &elua(!a delas&an apa4la (uu&an 7! 'o(m edu&as
d4utu&an tda& dpt dla&sana&an )D*
1 do&umen (uu&an 4e(s nama dan 'asltas pela7anan 'o(m (uu&an
&eseatan 7! mene(ma dan nama o(! 7an!
men7etuu mene(ma ps )D*
2 do&umen (uu&an 4e(s alasan ps d(uu&, memuat 'o(m (uu&an
&onds ps dan &e4utuan pela7anan le4 lanut )D*
A%K $32
" Do&umen (uu&an u!a memuat p(osedu( dan 'o(m (uu&an

nte(6ens 7an! suda dla&u&an )D*
# p(oses (uu&an de6aluas dalam aspe& mutu dan lapo(an mutu
&eselamatan ps )D,O,-*
1 %e!ulas untu& t(anspo(tas ps sesua d!n SK, Pedoman/Panduan, SPO
&e4utuann7a 7! melput ass &e4utuan t(anspo(tas,
o4at, 4aan meds a4s pa&a, se(ta al&es dan
pe(alatan meds sesua d!n &e4utuan ps ) % *
2 +e(dasa( atas asl ass, alat t(anpo(tas 7! d!una&an Standa( Am4ulane

A%K >
ut& (uu&an a(us sesua d!n &onds dan &e4utuan
ps dan memenu &etentuan &eselamatan t(anspo(tas
te(masu& memenu pe(s7a(atan PPI )D,O,-*
# me&ansme untu& menan!an &eluan p(oses alu( me&ansme sol6e omplan

t(anspo(tas dlm (uu&an )D,-*
1 Ada (e!ulas tentan! a& dan &e8a4an SK, Pedoman/Panduan, SPO
pasen dan &elua(!a ) % *
2 Pmpnan (uma sa&t memaam a& se(ta sosalsas d(e&tu(
&e8a4an pasen dan &elua(!a
se4a!amana dtetap&an dalam pe(atu(an
pe(undan!:undan!an )-*
" %umasa&tmen!o(mata&se(ta&e8a4an
pasendandalam&ondste(tentu te(adap
;PK 1 &elua(!a pasen 4a8a pasen meml& a&
untu& menentu&an n'o(mas apa saa 7an!
dapat dsampa&an pada &elua(!a dan
pa& lan3 )D,-*3
# Semua sta' mempe(ole edu&as dan sosalsas a&.&e8a4an pasen,

memaam tentan! a& se(ta &e8a4an
pasen dan &elua(!a, u!a dapat
menelas&an tan!!un! a8a4n7a
melndun! a& pasen3 )D,-*3
1 A!ama, &e7a&nan, dan nla:nla p(4ad 'o(m edu&as &e(oanan

pasen te(dent'&as )D,-*
2 Sta'mem4e(&anasuanden!ana(amen!o 'o(m pe(moon n &e(oanan
(mata!ama,&e7a&nan,dannla: nla p(4ad
;PK 131 pasen )D,-*
" %uma sa&t menan!!ap pe(mntaan (utn, mou pemu&a a!ama, 'o(mul( &e(oanan
te(masu& pe(mntaan &omple&s te(&at
du&un!an a!ama atau 4m4n!an
&e(o&anan3 )D,-,S*3
1 Ada (e!ulas tentan! &e8a4an smpan SK, Pedoman/panduan, SPO
(aasa pasen dan men!o(mat &e4utuan
p(6as pasen3 ) % *
2 Ada 4u&t pasen d4e(tau 4a8a se!ala 'o(mul( !ene(al onsent
n'o(mas tentan! &eseatan pasen adala
(aasa dan &e(aasaan tu a&an da!a
sesua den!an pe(atu(an pe(undan!:
undan!an3 )D,-*
" Pasen dmnta pe(setuuann7a untu& TTD pasen dan &elua(!a d 'o(mul(
pelepasan n'o(mas 7an! tda& te(a&up
;PK 132 dalam pe(atu(an pe(undan!:undan!an3
)D,-*3
# %umasa&tmen!o(mat&e(aasaann'o(m 'o(mul( p(6as
as&eseatanpasen3)D,-*3
$ Sta' men!dent'&as a(apan dan 'o(m !ene(al onsent . p(6as
&e4utuan p(6as selama pela7anan dan
pen!o4atan3 )D,O,-*
> Ken!nana&an&e4utuanpasenuntu&p(6as
do(matsaat8a8ana(a&lns,
peme(&saan, p(osedu(, pen!o4atan, dan
t(ans'e( pasen3 )O,-*
1 Ada (e!ulas tentan! pen7mpanan 4a(an! SK, Pedoman/panduan, SPO
ml& pasen 7an! dttp&an dan 4a(an! ml&
pasen &a(ena pasenn7a tda& dapat
mena!a a(ta ml&n7a3 %uma sa&t
memast&an 4a(an! te(se4ut aman dan
menetap&an tn!&at tan!!un! a8a4n7a
atas 4a(an! ml& pasen te(se4ut3 ) % *
;PK 13"
2 'o(mul( 4a(an! p(4ad
Pasenmene(man'o(mastentan!tan!!un!
a8a4(umasa&tdalammena!a 4a(an! ml&
pasen3 )D,-*
1 %uma sa&t menetap&an (e!ulas untu& SK, Pedoman/panduan, SPO
mela&u&an dent'&as populas pasen 7an!
(entan te(adap (s&o &e&e(asan dan
melndun! semua pasen da( &e&e(asan
)%*
2 Dae(a te(penl, dae(a te(solas, dan pantau t6

;PK 13#
(a8an te(adn7a tnda& &e&e(asan d (uma
sa&t dmonto( )O,-*
" Sta' (uma sa&t memaam pe(an me(e&a poste( da'ta( &elompo& 4e(s&o &e&e(asan
dalam tan!!un! a8a4n7a dalam
mela&sana&an p(oses pe(lndun!an3
)D,O,-*
1 Ada (e!ulas tentan! (uma sa&t SK, Pedoman/panduan, SPO
mendo(on! pa(tspas pasen dan &elua(!a
dalam p(oses asuan dan mem4e(
&esempatan pasen untu& mela&sana&an
seondopnontanpa(asa&a8at(a&anmeme
n!a(up(osesasuann7a3 ) % *
;PK 2
2 Sta'dlatdante(latmela&sana&an(e!ulass TO% d&lat ;PK < Se(t'&at Edu&ato(

e(tape(ann7adalammendu&un! a& pasen
dan &elua(!a untu& 4e(pa(tspas dalam
p(oses pela7anann7a3 )D,- ,S*
1 Ada (e!ulas tentan! a& pasen untu& SK, Pedoman/panduan, SPO
mendapat&an n'o(mas tentan! &onds,
da!noss past, (enana asuan, dan dapat
4e(pa(tspas dalam pen!am4lan
&eputusan se(ta d4e(tau tentan! asl
asuan te(masu& &emun!&nan asl 7an!
tda& te(du!a3) % *
2 Pasen d4e( n'o(mas tentan! &onds

meds me(e&a dan da!noss past )D,-*
" Pasen d4e( n'o(mas tentan! (enana n'o(med onsent
asuan dan tnda&an 7an! a&an dla&u&an
dan 4e(pa(tspas dalam pen!am4lan
&eputusan )D,-*
;PK 231 # Pasen d4e( tau 4lamana pe(setuuan n'o(med onsent
tnda&an )n'o(med onsent* dpe(lu&an dan
4a!amana p(oses mem4e(&an
pe(setuuan3 )D,-*
$ Pasen delas&an dan memaam tentan! 'o(mul( edu&as
asl 7an! da(ap&an da( p(oses asuan
dan pen!o4atan )D,-*
> Pasen delas&an dan memaam 4la 'o(mul( edu&as &oson!
te(ad &emun!&nan asl 7an! tda&
te(du!a )D,-*
 Pasen se(ta &elua(!a delas&an dan
memaam tentan! a&n7a dalam
4e(pa(tspas mem4uat &eputusan te(&at
asuan &a dn!n&an )-*
1 Ada (e!ulas 7an! men!atu( pela&sanaan SK, Pedoman/panduan, SPO
p(oses untu& mena8a4 pe(tan7aan
n'o(mas &ompetens dan &e8enan!an da(
PPA ) % *
2 Pasend4e(n'o(mastentan!elemena*samp n'o(med onsent
;PK 232
aden!an*7an!(ele6anden!an &onds dan
(enana tnda&an )D,-*
" DP=P, PP=A, dan PPA lann7a a(us
mempe(&enal&an d( saat pe(tama &al
4e(temu pasen3 ) -,S*
1 %uma sa&t mem4e(tau&an pasen se(ta 'o(m penola&an
&elua(!an7a tentan! a& me(e&a untu&
menola& atau tda& melanut&an
pen!o4atan3 )D,-*
2 %umasa&tmem4e(tau&anpasendan&elu 'o(m penola&an
a(!an7atentan!&onse&uensda( &eputusan
me(e&a )D,-*
;PK 23" " %umasa&tmem4e(tau&anpasense(ta&el 'o(m penola&an
ua(!an7atentan!tan!!un!a8a4 me(e&a
4e(&atan den!an &eputusan te(se4ut )D,-*
# %uma sa&t mem4e(tau&an pasen se(ta 'o(m seond opnon??

&elua(!an7a tentan! te(sedan7a alte(nat'
pela7anan dan pen!o4atan )D,-*
1 Ada (e!ulas (uma sa&t pada saat pasen SK, Pedoman/panduan, SPO
menola& pela7anan (esustas, menunda
atau melepas 4antuan dup dasa( sesua
den!an pe(atu(an pe(undan!:undan!an,
;PK 23# no(ma a!ama, dan 4uda7a mas7a(a&at) % *
2 Pela&sanaansesuaden!an(e!ulaste(se4ut3 'o(mul( penola&an

)D,-*
1 Ada(e!ulastentan!asesmendanmanaemen SK, Pedoman/panduan, SPO
n7e( ) % *
2 %uma sa&t men!o(mat se(ta 5o(m Ass N7e(
mendu&un! a& pasen den!an mela&u&an
asesmen dan manaemen n7e( 7an!
sesua3 )D,-*
;PK 23$
" Sta' (uma sa&t memaam pen!a(u 5o(m Ass N7e(
p(4ad, 4uda7a, sosal, dan sp(tual tentan!
a& pasen untu& melapo(&an (asa n7e(,
asesmen, dan manaemen n7e(
sea(a a&u(at )D,-*
1 Ada(e!ulastentan!pela7ananpasenpadaa& SK, Pedoman/panduan, SPO
(&edupan ) % *
2 %uma sa&t men!a&u dan men!dent'&as
pasen 7an! men!adap &ematan den!an
&e4utuan 7an! un&3 )D,-*
;PK 23>
" Sta' (uma sa&t men!o(mat a& pasen
7an! sedan! men!adap &ematan,
meml& &e4utuan 7an! un& dalam p(oses
asuan, dan ddo&umentas&an3 )D,-*
1 Ada (e!ulas 7an! mendu&un! &onsstens SK, Pedoma/panduan, SPO

pela7anan dalam men!adap &eluan,
&on'l&, atau 4eda pendapat3 ) % *
2 Pasen d4e(tau tentan! p(oses lea'let, 'o(mul( &eluan

men7ampa&an &eluan, &on'l&, atau
;PK " pe(4edaan pendapat3 )D,-*
" Keluan, &on'l&, dan pe(4edaan pendapat Kota& sa(an < 5o(m
dtelaa se(ta dtnda&lanut ole (uma
sa&t se(ta ddo&umentas&an3 )D,-*
# Pasendanatau&elua(!apasen&utse(tadala 'o(m sa(an

mp(osespen7elesaan3)D,-*
1 Ada(e!ulas4a8asetappasense(ta&elua(! SK, Pedoma/panduan, SPO
amendapat&ann'o(mastentan! a& dan
&e8a4an pasen3 ) %*
2 Ada 4u&t 4a8a n'o(mas tentan! a& 4anne(
se(ta &e8a4an pasen d4e(&an te(tuls
;PK # &epada pasen, te(pampan!, atau te(seda
sepanan! 8a&tu3 )D,O,-*
" %umasa&tmenetap&anp(osespem4e(ann'
o(masa&dan&e8a4anpasen &a
&omun&as tda& e'e&t' atau tda& tepat3
)-,S*
1 Ada(e!ulastentan!pe(setuuanumumdanpe SK, Pedoman/panduan, SPO
ndo&umentasann7adalam(e&am meds
pasen d lua( tnda&an 7an! mem4utu&an
pe(setuuan &usus )n'o(med onsent*
te(send(3 ) %*
2 Pe(setuuan umum )!ene(al onsent* 5o(m !ene(al onsent

;PK $ dmnta saat pe(tama &al pasen masu&
(a8at alan atau setap masu& (a8at nap3
)D,-*
" Pasen dan atau &elua(!a dmnta untu& 5o(m !ene(al onsent
mem4aa, lalu menandatan!an
pe(setuuan umum )!ene(al onsent*3 )D,-*
1 Ada (e!ulas 7an! da4a(&an den!an elas SK, Pedoman/panduan, SPO

men!ena pe(setuuan &usus )n'o(med
onsent*3 ) %*
2 DP=P menelas&an n'o(mas tnda&an 7an! TTD 6e('&as dlm I
a&an dam4l dan 4la pe(lu dapat d4antu
sta' te(lat3 )D,-*
;PK $31 " Pasen memaam n'o(mas tnda&an 7an! 5o(m I
meme(lu&an pe(setuuan &usus )n'o(med
onsent* melalu a(a dan 4aasa 7an!
dmen!e(t ole pasen3 Pasen dapat
mem4e(&an/menola& pe(setuuan &usus
)n'o(med onsent* te(se4ut3 )D,-*
1 Ada (e!ulas tentan! pe(setuuan &usus SK, Pedoman/panduan, SPO
)n'o(med onsent* 7an! a(us dpe(ole
se4elum ope(as atau p(osedu( n6as',
se4elum anestes )te(masu& sedas*,
pema&aan da(a dan p(odu& da(a, se(ta
pen!o4atan (s&o tn!! lann7a3 ) %*
2 Ada 4u&t pela&sanaan tentan! pe(setuuan SIA/SIO

&usus )n'o(med onsent* 7an! a(us
dpe(ole se4elum ope(as atau p(osedu(
n6as', se4elum anestes )te(masu&
;PK $32 sedas*, pema&aan da(a dan p(odu&
da(a, se(ta pen!o4atan (s&o tn!!
lann7a3 )D, -*
" uma sa&t men7usun da'ta( semua Lst tnda&an n6as'

pen!o4atan/tnda&an/p(osedu( 7an!
meme(lu&an pe(setuuan &usus )n'o(med
onsent*3 )D,-*
# IdenttasDP=Pdano(an!7an!mem4antume TTD 6e('&as dlm I
m4e(&ann'o(mas&epadapasen se(ta
&elua(!a datat d (e&am med& pasen3
)D,-*
1 Ada (e!ulas sesua den!an pe(atu(an SK, Pedoman/panduan, SPO
pe(undan!:undan!an 7an! menetap&an
p(oses dan sapa 7an! menandatan!an
pe(setuuan &usus )n'o(med onsent* 4la
pasen tda& &ompeten3 ) %*
2 %uma sa&t menetap&an dan 5o(m I

mela&sana&an p(oses apa4la o(an! lan
;PK $3" 7an! mem4e( pe(setuuan &usus
)n'o(med onsent*3 )D,-*
" Namao(an!7an!men!!ant&anpem4e(pe(s 5o(m I
etuuandalampe(setuuan&usus )n'o(med
onsent* sesua den!an pe(atu(an
pe(undan!:undan!an te(atat d (e&am
med&3 )D,-*
;PK >:C TDD
1 %uma sa&t menentu&an s, umla, dan ens SK, Pedoman/panduan, SPO
asesmen a8al pada dspln meds dan &epe(a8atan
sesua d* sampa den!an n* d ma&sud dan tuuan3
) %*
AP 1
2 Ada4u&tpela&sanaans,umladanensasesmena8ald 'o(m ass a8al meds
splnmeds3)D,- *
" Ada 4u&t pela&sanaan s, umla dan ens asesmen 'o(m ass a8al pe(a8at
a8al dspln &epe(a8atan3 )D,-*
# Ada4u&t&ete(l4atan&elua(!adalammelen!&apasesme 5o(m ass a8al
na8al )D,-*
1 Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al
nap melput (8a7at &eseatan pasen dan
peme(&saan 's& )D,-*
2 Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al
nap melput 'a&to( 4o: ps&o:soso:&ultu(al:sp(tual3
)D,-*
AP 1.1
" 4u&t pela&sanaan ass a8al (anap men!asl&an 5o(m ass a8al
da!nosa a8al dan masala &eseatan pasen )D,-*
# Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al
nap a(us selesa dalam 8a&tu 2# am atau le4
epat sesua den!an &onds pasen3 )D,-*
$ Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al
nap men!asl&an (enana asuan )D,-*
1 %umasa&tmenetap&an&e(an!&a8a&tupen7elesaana SK, Pedoman/Panduan, SPO
sesmena8alpasen (a8at alan3 ) %*
2 Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al (aal
alan melput (8a7at &eseatan pasen dan
peme(&saan 's&3 )D,-*
" Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al (aal
alan melput 'a&to( 4o: ps&o:soso:&ultu(al:sp(tual3
)D,-*
# Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al (aal
AP 1.2 alan men!asl&an da!noss a8al dan masala
&eseatan pasen )D,-*
$ Ada 4u&t pela&sanaan asesmen a8al pasen (a8at 5o(m ass a8al (aal
alan men!asl&an (enana asuan3 )D,-*
> Ada 4u&t pela&sanaan pasen (a8at alan den!an 'o(m ass a8al ulan! (aal
pen7a&t a&ut /non &(ons, asesmen a8al dpe(4aa(u
setela 1 )satu* 4ulan3 )D,-*
 da 4u&t pela&sanaan pasen (a8at alan den!an 'o(m ass a8al ulan! (aal
pen7a&t &(ons, asesmen a8al dpe(4aa(u setela "
)t!a* 4ulan3 )D,-*
1 %umasa&tmenetap&an&e(an!&a8a&tupen7elesaana SK, Pedoman/panduan, SPO
sesmena8alpasen !a8at da(u(at3 ) %*
2 Ada 4u&t pela&sanaan asesmen a8al pasen !a8at 'o(m ass a8al I@D
da(u(at melput (8a7at &eseatan pasen dan
peme(&saan 's&3 )D,-*
" Ada4u&tpela&sanaanasesmena8alpasen!a8atda(u(a 'o(m ass a8al I@D
AP 1.3 tmelput'a&to(4o: ps&o:soso:&ultu(al:sp(tual
4e('o&us pada &onds pasen3 )D,-*
# Ada 4u&t pela&sanaan asesmen a8al pasen !a8at 'o(m ass a8al I@D
da(u(at men!asl&an da!noss a8al dan masala
&eseatan pasen )D,-*
$ Ada 4u&t pela&sanaan asesmen a8al pasen !a8at 'o(m ass a8al I@D
da(u(at men!asl&an (enana asuan )D,-*
1 %uma sa&t menetap&an &(te(a (s&o nut(sonal SK, Pedoman/panduan, SPO
7an! d&em4an!&an 4e(sama sta' 7an! &ompeten dan
4e(8enan!3 ) %*
AP 1.4 2 Pasen ds&(nn! untu& (s&o nut(sonal se4a!a 'o(m ass a8al !B
4a!an da( asesmen a8al )D,-*
" Pasenden!an(s&onut(sonaldlanut&anden!anases 'o(m ass a8al !B
men!B3)D,-*
1 %S menetap&an &(te(a asesmen &e4utuan SK, Pedoman/panduan, SPO
'un!sonal dan (s&o atu, 7an! d&em4an!&an
4e(sama sta' 7an! &ompeten dan 4e(8enan!3 ) %*
AP 1.4.1 2 Pasen ds&(nn! untu& &e4utuan 'un!sonal 'o(m ass (es&o atu
te(masu& (s&o atu )D,-*
" Pasen den!an &e4utuan 'un!sonal lanutan 'o(m ass (es&o atu
te(masu& (s&o atu, mempe(ole asuan 7an!
sesua &etentuan %S3 )D,-*
1 %umasa&tmenetap&an(e!ulaspasends&(nn!untu&( SK, Pedoman/panduan, SPO
asan7e( ) %*
2 Apa4la ddent'&as ada (asa n7e( pada asesmen pont dlm 'o(m ass a8al
a8al, la&u&an asesmen le4 mendalam, sesua
den!an umu( pasen, dan pen!u&u(an ntenstas dan
AP 1.5 &ualtas n7e( sepe(t &a(a&te(, &e&e(apan/'(e&uens,
lo&as dan laman7a )D,-*
" Asesmen datat sedem&an sen!!a mem'asltas 'o(m ass n7e( lanutan
asesmen ulan!an 7an! te(atu( dan tnda& lanut sesua
&(te(a 7an! d&em4an!&an ole (uma sa&t dan
&e4utuan pasen3 )D,-*
1 %umasa&tmenetap&an(e!ulastentan!asesmentam4 SK, Pedoman/panduan, SPO
aanuntu&populas pasen te(tentu ) %*
AP 1.6 2 Te(adap populas pasen te(se4ut dla&sana&an
asesmen tam4aan sesua (e!ulas (uma sa&t3
)D,-*
1 Ada (e!ulas tentan! asesmen ulan! ole do&te( SK, Pedoman/panduan, SPO
penan!!un! a8a4 pem4e( pela7anan )DP=P*,
pe(a8at dan p(o'esonal pem4e( asuan )PPA*
lann7a untu& e6aluas (espons pasen te(adap
asuan 7an! d4e(&an se4a!a tnda& lanut3 ) %*
2 Ada 4u&t pela&sanaan asesmen ulan! meds 'o(m ass ulan!

dla&sana&an mnmal satu &al sea(, te(masu& a&(
mn!!u / l4u( untu& pasen a&ut )D,-*
" Ada4u&tpela&sanaanasesmenulan!olepe(a8atmnm SOPIE PPT
alsatu&alpe(s't atau sesua den!an pe(u4aan
&onds pasen3 )D,-*
# Ada 4u&t asesmen ulan! ole p(o'esonal pem4e( SOAP PPT
asuan )PPA* lann7a dla&sana&an den!an nte(6al
sesua (e!ulas (uma sa&t3 )D,-*
$ Asesmen ulan! datat d do&umen atatan PPT
Pe(&em4an!an Pasen Te(nte!(as )PPT*3 )D*
1 %umasa&tmenetap&anpen!atu(anu(utanpen7mpana SK, Pedoman/panduan, SPO
nlem4a(:lem4a(%M a!a( muda da( &em4al da&ses
dan te(standa(, p(o'esonal pem4e( asuan )PPA*
dapat menemu&an dan mena( &em4al asl
AP 2.1 asesmen d (e&am meds3 )Masu&&an &e MI%M*3 ) %*
2 Asesmen ulan! datat d do&umen atatan SOAP PPT

Pe(&em4an!an Pasen Te(nte!(as )PPT*3 )D*
1 Ada (e!ulas 7an! menetap&an p(o'esonal pem4e( SK, Pedoman/panduan, SPO
asuan )PPA* 7an! &ompeten dan 4e(8enan!
mela&u&an asesmen a8al, asesmen ulan! dan
asesmen !a8at da(u(at3 ) %*
2 Asesmen a8al, asesmen ulan! dan asesmen !a8at TTD sta' meds dlm 'o(m ass
da(u(at an7a dla&sana&an ole meds 7an!
&ompeten dan 4e(8enan! )D,-*
AP 3
" Asesmen a8al, asesmen ulan! dan asesmen !a8at TTD sta' meds dlm 'o(m ass
da(u(at an7a dla&sana&an ole pe(a8at 7an!
&ompeten dan 4e(8enan!3 )D,-*
# Asesmen a8al, asesmen ulan! dan asesmen !a8at TTD sta' meds dlm 'o(m ass
da(u(at an7a dla&sana&an ole p(o'esonal pem4e(
asuan )PPA* lann7a 7an! &ompeten dan 4e(8enan!3
)D,-*
1 Ada 4u&t asl asesmen a8al dan asesmen ulan! 'o(m ass a8al dan ulan! PPA
ole masn!:masn! p(o'esonal pem4e( asuan
)PPA* dnte!(as&an3 )D,-*
2 Ada4u&taslasesmendanalssuntu&mem4uat(enan 'o(m ass a8al dan ulan! PPA
aasuan3)D,-*
AP 4
" +e(dasa(&an asl asesmen dan (enana asuan PPT
p(o'esonal pem4e( asuan )PPA* lann7a, do&te(
penan!!un! a8a4 pem4e( pela7anan )DP=P*
men!nte!(as&an (enana asuan dan tnda&
lanutn7a )D,-*
1 Ada (e!ulas tentan! pen!o(!ansasan dan SK, Pedoman/panduan, SPO

pen!atu(an pela7anan la4o(ato(um sea(a
te(nte!(as3 ) %*
2 adapela&sanaanpela7ananla4o(ato(umte(seda2#am3 st&e( 2# am
)O,-*
" Adada'ta(spesalsdalam4dan!da!nost&&usus7an! lst no tlp spesals la4
dapatdu4un!&a d4utu&an )-*
AP.5
# Ada 4u&t pemlan la4o(ato(um d lua( (uma sa&t MOU
)pa& &et!a* untu& &e(asama 4e(dasa(&an pada
se(t'&at mutu dan d&ut pe(anan &e(asama sesua
pe(atu(an pe(undan!:undan!an3 )D,-*
$ Ada 4u&t pela&sanaan (uu&an la4o(ato(um &elua( 'o(m la4
(uma sa&t )pa& &et!a* a(us melalu la4o(ato(um
(uma sa&t3 )D,-*
1 %uma sa&t menetap&an seo(an! )atau le4* tena!a SK penunu&&an DP=P d(3de8
p(o'esonal untu& memmpn pela7anan la4o(ato(um
te(nte!(as dse(ta u(aan tu!as, tan!!un! a8a4 dan
8e8enan! sesua 4ut( a* s/d e* dalam Ma&sud dan
Tuuan3 ) %*
2 Ada4u&tpela&sanaanpen7usunandane6aluas(e!ulas3 alu( la4o(ato(um

)D,-*
AP 5.1 " Ada4u&tpela&sanaanpela7ananla4o(ato(umsesua(e! lapo(an e6aluas
ulas3)D,-*
# Ada4u&tpen!a8asanpela&sanaanadmnst(as3)D,-*
$ Ada4u&tpela&sanaanp(o!(am&endalmutu3)D,-* data PMI . PME pe( taun
> Ada 4u&t pela&sanaan monto(n! dan e6aluas semua lapo(an e6aluas pe( 4ulan
ens pela7anan la4o(ato(um3 )D,-*
1 %uma sa&t mela&u&an analss pola &etena!aan sta' data analss pola &etena!aan
la4o(ato(um 7an! ade&uat untu& memenu
&e4utuan pasen )D,-*
2 Sta' la4o(ato(um 7an! mem4uat nte(p(etas, 4u&t &(edensal anals dan Sp3PK
memenu pe(s7a(atan &(edensal3 )lat u!a KPS3#,
EP 1*3 )D,-*
AP 5.2
" Sta' la4o(ato(um dan sta' lan 7an! mela&sana&an tes 4u&t &(edensal
te(masu& 7an! men!e(a&an Tes d %uan! %a8at
)T%% / Pont o' a(e Testn!* pasen, memenu
pe(s7a(atan &(edensal )D,-*
# Adapela&sanaansupe(6spela7ananla4o(ato(umd(um SPO 6aldas
asa&t3)%,D*
1 Ada p(o!(am manaemen (s&o menan!an potens SK, Pedoman/panduan, SPO
(s&o d la4o(ato(um sesua (e!ulas (uma sa&t3 ) %*
2 Ada 4u&t pela&sanaan p(o!(am manaemen (s&o lapo(an manaemen (s&o la4 &e &omte PPI
se4a!a 4a!an da( manaemen (s&o (uma sa&t dan
p(o!(am pene!aan dan pen!endalan n'e&s3 )D,-*
AP 5.3
" Ada 4u&t lapo(an &epada pmpnan (uma sa&t paln! 4u&t lapo(an nsden
sed&t satu taun se&al dan 4la ada &eadan3 )D,-*
# Ada pela&sanaan o(entas dan pelatan se(t'&at

4e(&elanutan )on!on!* 4a! sta' la4o(ato(um tentan!
p(osedu( &eselamatan dan &eamanan untu&
men!u(an! (s&o se(ta pelatan tentan! p(osedu(
4a(u 7an! men!!una&an 4aan 4e(4aa7a3)D,-*
1 Ada4u&tuntla4o(ato(ummela&sana&anmanaemen(s 'o(m MSDS/LDP
&o'asltasdan(s&o n'e&s sesua (e!ulas d (uma
sa&t )D,-*
2 Ada 4u&t pelapo(an dan penan!anan sta' 7an! 'o(m papa(an nsden
te(papa( d unt la4o(ato(um datat sesua den!an
(e!ulas PPI (uma sa&t dan pe(atu(an pe(undan!an
)D,-*
AP 5.3.1
" Ada 4u&t unt la4o(ato(um menalan&an &etentuan 4u&t e6aluas
sesua den!an 4ut( a* sampa den!an !* d ma&sud
dan tuuan3 )D, -*
# Ada4u&tdla&u&antnda&an&o(e&s,datat,de6aluasda pelapo(an nsden &e K" %S
ndlapo(&an&epada Penan!!un! a8a4 / &oo(dnato(
K" %S =&a munul masala dan te(ad &eela&aan3
) D,- *
1 Ada (e!ulas 7an! dsusun sea(a &ola4o(at' tentan! SK, Pedoman/panduan, SPO
asl la4o(ato(um 7an! &(ts, pelapo(an ole sapa
dan &epada sapa se(ta tnda& lanutn7a3 ) %*
2 ;asl la4o(ato(um 7an! &(ts datat ddalam (e&am dlamp(&an dlm %M

AP 5.3.2 meds pasen )lat u!a SKP 2 31 EP 2 * )D,-*
" Ada 4u&t tnda& lanut da( pelapo(an asl 'o(m nla &(ts
la4o(ato(um 7an! &(ts sea(a &ola4o(at'3 )D,-*
# Ada4u&tpela&sanaane6aluasdantnda&lanutte(adap lapo(an e6aluas la4
selu(up(osesa!a( memenu &etentuan se(ta
dmod'&as sesua &e4utuan3 )D,-*
1 %uma sa&t menetap&an &e(an!&a 8a&tu SK, Pedoman/panduan, SPO
pen7elesaan peme(&saan la4o(ato(um3 ) %*
AP 5.4
2 Ada 4u&t penatatan dan e6aluas 8a&tu te(lamp( dlm asl la4, 8a&tu pe(&sa dan
pen7elesaan peme(&saan la4o(ato(um3 )D,-* 8a&tu &elua( asl
" Ada 4u&t penatatan dan e6aluas 8a&tu te(lamp( dlm asl la4, 8a&tu pe(&sa dan
pen7elesaan peme(&saan to3 )D,-* 8a&tu &elua( asl
1 Ada (e!ulas dan p(o!(am untu& pen!elolaan SK, Pedoman/panduan, SPO
pe(alatan la4o(ato(um 7an! melput 4ut( a* sampa
den!an * dalam Ma&sud dan Tuuan3 ) %*
2 Ada 4u&t sta' 7an! te(lat mela&sana&an u 'un!s da'ta( &unun!an te&ns
dan ddo&umentas&an3 )D,-*
" Ada 4u&t sta' 7an! te(lat mela&sana&an nspe&s Lst mantane alat
4e(&ala dan ddo&umentas&an3 )D,-*
# Ada 4u&t sta' 7an! te(lat mela&sana&an Lst mantane alat
pemela(aan 4e(&ala dan ddo&umentas&an3 )D,-*
AP 5.5 $ da 4u&t sta' 7an! te(lat mela&sana&an &al4e(as Lst mantane alat
> Adada'ta(n6enta(spe(alatanla4o(ato(um3)D* lst n6esta(s
 Ada4u&tpela&sanaanmonto(n!dantnda&ante(adap& da'ta( &e!a!alan sampel dan da'ta(
e!a!alan'un!salat dan ddo&umentas&an3 )D,-* &unun!an te&ns
C Ada 4u&t pela&sanaan 4la te(ad p(oses pena(&an
)(eall* dan ddo&umentas&an3 )D,-*
F Te(adap &e!atan a* sampa den!an * d ma&sud lapo(an te&ns pe( 4ulan/taun, lapo(an
dan tuuan dla&u&an e6aluas 4e(&ala dan tnda& lanut e6aluas
1 %uma sa&t menetap&an pen!elolaan lo!st& SK, Panduan/pedoman, SPO

la4o(ato(um, (ea!ensa esensal , 4aan lan 7an!
dpe(lu&an, te(masu& &onds 4la te(ad &e&oson!an
sesua pe(atu(an pe(undan!an3 )lat u!a M5K3$, EP
1*3 ) %*
AP 5.6 2 Ada 4u&t pela&sanaan semua (ea!ensa esensal la4el dse(ta t!l dt! dan t!l 4u&a, dsmpan
dsmpan dan d4e( la4el, se(ta ddst(4us sesua dlm &ul&as suu te(tentu
pedoman da( pem4uatn7a atau nst(u&s pada
&emasann7a )lat u!a M5K3$, EP 2*3 )D,O,-*
" Ada4u&tpela&sanaane6aluas/audtsemua(ea!en3 lapo(an audt (ea!en pe( 4ulan
)D,-*
1 Ada (e!ulas tentan! pen!am4lan, pen!umpulan, SK, Panduan/pedoman, SPO
dent'&as, pen!e(aan, pen!(man, pem4uan!an
spesmen ) %*
2 ada 4u&t pela&sanaan pe(mntaan peme(&saan ole 'o(m pe(mntaan la4 &e(tas/onlne
p(o'esonal pem4e( asuan )PPA* 7an! &ompeten
dan 4e(8enan! )D,-*
" Ada 4u&t pela&sanaan pen!am4lan, pen!umpulan pemasan!an 4a(ode pd sampel
dan dent'&as spemen sesua den!an (e!ulas
)D,-*
AP 5.7 # Ada 4u&t pela&sanaan pen!(man, pem4uan!an, 4u&u lapo(an spesmen
pen7mpanan, pen!a8etan spemen sesua den!an
(e!ulas )D,-*
$ da4u&tpela&sanaanpene(maan,pen7mpanan,telusu(s 4u&u lapo(an pen!ulan!an spesmen
pesmen)t(a&n!* sesua den!an (e!ulas3 )D,-*
> Ada 4u&t pen!elolaan peme(&saan a(n!an / a(an asl la4 PA . a(an tu4u
sesua den!an (e!ulas3 )D,-*
 Dtetap&an p(osedu( 4la men!!una&an la4o(ato(um 'o(m la4 (uu&an
(uu&an3 )D*
1 Ada (e!ulas tentan! penetapan dan e6aluas (entan! SK, Panduan/pedoman, SPO
nla no(mal untu& nte(p(etas, pelapo(an asl la4
&lns3 )% *
AP 5.8
2 Peme(&saan la4o(ato(um a(us dlen!&ap den!an pe(mntaan te(tuls 6a a
pe(mntaan peme(&saan te(tuls dse(ta den!an
(n!&asan &lns3 )D,-*
" Setapaslpeme(&saanla4o(ato(umdlen!&apden!an te(antum dlm asl la4
(entan!nlano(mal3 )D*
1 %umasa&tmenetap&anp(o!(ammutula4o(ato(um&ln SK, Panduan/pedoman, SPO
&melputa*sampa den!an e* d ma&sud dan tuuan3
) %*
2 Ada4u&tpela&sanaan6aldasmetodates3)D,-* te(antum dlm asl la4 nama 6aldato(
AP 5.9
" Ada 4u&t pela&sanaan su(6elans a(an dan 4u&u pen!elua(an asl d TTD ole
penatatan asl peme(&saan3 )D,-* su(6elans
# Ada4u&tpela&sanaantes(ea!en3)D,-* 4u&u lapo(an Gualt7 ont(ol (ea!en
$ Ada 4u&t pela&sanaan tnda&an &o(e&s epat dan 4u&u &o(e&s epat
do&umentasn7a te(adap masala 7an! tm4ul3 )D,-*
1 Ada4u&tpela&sanaanPME3)D* 4u&t lapo(an

AP 5.9.1 2 Ada4u&ttnda&lanutda(aslPME3)D* asl pen!e(aan PME dlm 4entu& lapo(an
1 Ada4u&tndanatause(t'&asla4o(ato(um(uu&an3 4u&t n/se(t'&at p(oda . 4omed

)D,-*
2 Ada4u&tpela&sanaanPMEla4o(ato(um(uu&an3)D,-* opan lapo(an PME p(oda . 4omed/
se(t'&at PME
AP 5.10 " Ada sta' 7an! 4e(tan!!un!a8a4 atas asl 4u&u 6aldas asl peme(&saan la4 (uu&an
peme(&saan la4o(ato(um 7an! d4e(&an3 )D,-*
# Lapo(an taunan PME la4o(ato(um (uu&an lapo(an PME taunan/ se(t'&at PME
dse(a&an &epada pmpnan (uma sa&t untu&
e6aluas &ont(a& &lns taunan3 )D,-*
1 Ada (e!ulas tentan! pen7edaan dan pela7anan SK, Panduan/pedoman, SPO
da(a melput a* sampa den!an d* d ma&sud dan
tuuan sesua den!an pe(atu(an pe(undan!:
undan!an3 ) %*
2 Pem4e(an da(a a(us mendapat&an pe(setuuan da( su(at pe(setuuan dlamp(&an
pasen atau &elua(!a, 7an! se4elumn7a tela
mendapat&an penelasan tentan! tuuan, man'aat,
AP 5.11 (s&o dan &ompl&as pem4e(an t(ans'us da(a dan
p(odu& da(a )Lat u!a ;PK3231 EP #, SKP 1 EP #*3
)D,-
" Ada4u&tdla&sana&anmonto(n!dane6aluaspem4e(a 'o(m mont(n! t(ans'us

nt(ans'usda(adan p(odu& da(a dan dlapo(&an 4la
te(ad (ea&s t(ans'use )Lat u!a PAP3"3" dan
PMKP311*3 )D,-*
1 Seo(an! p(o'esonal 7an! &ompeten dan 4e(8enan!, SK, Panduan/pedoman, SPO
dtetap&an 4e(tan!!un! a8a4 untu& pela7anan da(a
dan t(an'us )lat u!a, PAP3"3"H TK%S3F* ) %*
AP 5.11.1
2 Ada supe(6s melput a* sampa den!an d* d ma&sud 'o(m supe(6s

dan tuuan3 )D,-*
AP 5.11.2 1 Dtetap&anp(o!(am&endalmutu3) %* p(o&e( mutu

2 ada4u&tpela&sanaanp(o!(am&endalmutu3)D,-* lapo(an e6aluas
1 Ada (e!ulas tentan! pen!o(!ansasan dan SK, Panduan/pedoman, SPO
pen!atu(an pela7anan (adoda!nost&, man! dan
(adolo! nte(6ensonal sea(a te(nte!(as ) %*
2 Adapela7anan(adoda!nost&,man!dan(adolo!nte( o4se(6as dan 8a8ana(a
6ensonalte(seda2# am ) O, -*
" Ada da'ta( spesals dalam 4dan! da!nost& &usus lst no tlp spesals (adolo!
dapat du4un! &a d4utu&an ) D,- *
# Pemlan (adoda!nost&, man! dan (adolo! MOU
AP 6 nte(6ensonal d lua( (uma sa&t )pa& &et!a* untu&
&e(asama 4e(dasa(&an pada se(t'&at mutu dan d&ut
pe(anan &e(asama sesua pe(atu(an pe(undan!:
undan!an3 )D,-*
$ Ada 4u&t pela&sanaan (uu&an (adoda!nost&, 'o(m (uu&an

man! dan (adolo! nte(6ensonal &elua( (uma sa&t
)pa& &et!a* a(us melalu (adoda!nost&, man!
dan (adolo! nte(6ensonal (uma sa&t3 )D,-*
1 %uma sa&t menetap&an seo(an! )atau le4* tena!a SK penunu&&&an DP=P (adolo!
p(o'esonal untu& memmpn pela7anan
(adoda!nost&, man! dan (adolo! nte(6ensonal
te(nte!(as dse(ta u(aan tu!as, tan!!un! a8a4 dan
8e8enan! sesua 4ut( a* sampa den!an e* dalam
Ma&sud dan Tuuan3 )% *
2 Ada4u&tpela&sanaanpen7usunandane6aluas(e!ulas3 lapo(an e6aluas DP=P

)D,-*
AP 6.1 " Ada 4u&t pela&sanaan pela7anan (adoda!nost&, 'o(m pe(mntaan (adolo! / Onlne
man! dan (adolo! nte(6ensonalsesua (e!ulas3
)D,-*
# Ada4u&tpen!a8asanpela&sanaanadmnst(as3)D,-* lapo(an e6aluas DP=P
$ Ada4u&tpela&sanaanp(o!(am&endalmutu3)D,-* lapo(an mutu

> Ada 4u&t pela&sanaan monto(n! dan e6aluas semua lapo(an e6aluas
ens pela7anan (adoda!nost&, man! dan (adolo!
nte(6ensonal3 )D,-*
1 %umasa&tmela&u&ananalsspola&etena!aansta'(ad lapo(an pola &epe!a8aan sta'
oda!nost&,man! dan (adolo! nte(6ensonal )%I%*
)%I%* 7an! ade&uat untu& memenu &e4utuan
pasen )lat u!a TK%S F3Ep23 PMKP > EP 2* )D,-*
2 Sta' (adoda!nost&, man! dan (adolo! pe(s7a(atan &ual'&as sp3(ad

nte(6ensonal )%I%* )%I%* dan sta' lan 7an!
mela&sana&an tes te(masu& 7an! men!e(a&an
pela7anan pasen d tempat tdu( )pont:o':a(e test*
AP 6.2 pasen, memenu pe(s7a(atan &(edensal )lat u!a
KKS3#, EP 1*3 )D,-*
" Sta' (adoda!nost&, man! dan (adolo! pe(s7a(atan &ual'&as sp3(ad

nte(6ensonal )%I%* )%I%* 7an! mem4uat nte(p(etas /
e&pe(tse memenu pe(s7a(atan &(edensal )lat u!a
KKS3#, EP 1*3 )D,-*
# Ada pela&sanaan supe(6s pela7anan (adoda!nost&, lapo(an e6aluas
man! dan (adolo! nte(6ensonal )%I%* d (uma
sa&t3 )%, D*
1 %umasa&tmenetap&anp(o!(ammanaemen(s&omen SK, Panduan/pedoman, SPO
an!anpotens(s&o &eamanan (adas d pela7anan
)%I%* sesua 4ut( a* sampa den!an e* d ma&sud dan
tuuan ) lat u!a M5K # EP 1*3 ) %*
2 Ada 4u&t pela&sanaan p(o!(am manaemen (s&o lapo(an nsden papa(an
7an! me(upa&an 4a!an da( manaemen (s&o (uma
sa&t )(adas* dan p(o!(am pene!aan dan
pen!endalan n'e&s )D,-*
AP 6.3
" Ada4u&tlapo(an&epadapmpnan(umasa&tpaln!sed lapo(an &e d(e&tu(
&tsatutaunse&al dan 4la ada &eadan )lat u!a
M5K "*3 )D,-*
# Dada&an o(entas dan pelatan 4e(&elanutan se(t'&at
)on!on!* 4a! sta' (adoda!nost&, man! dan
(adolo! nte(6ensonal )%I%* tentan! p(osedu(
&eselamatan dan &eamanan untu& men!u(an! (s&o
se(ta pelatan tentan! p(osedu( 4a(u 7an!
men!!una&an 4aan 4e(4aa7a )lat u!a, M5K311H
TK%S3FH KKS3C*3 )D,O,-*
1 %uma sa&t menetap&an (e!ulas se4elum dla&u&an SK, Panduan/pedoman, SPO

peme(&saan (adoda!nost&, man! dan (adolo!
nte(6ensonal )%I%* a(us ada penelasan da(
%adolo!n7a dan a(us ada pe(setuuan da( pasen
atau &elua(!a ) % *
2 %uma sa&t mela&sana&an dent'&as doss

ma&smun (adas untu& setap peme(&saan
AP 6.3.1 %adoda!nost&, Iman! Dan %adolo! Inte(6ensonal,
)D,-*3
" adapela&sanaanedu&astentan!dossuntu&peme(&saa
nma!n!)D3-*
# Ada4u&t(s&o(adasddent'&asmelalup(oses7an!sp
es'&ataualat7an! spes'&, untu& sta' dan pasen 7an!
men!u(an! (s&o )ap(on, TLD dan 7an! seens* )lat
u!a M5K $ EP "*3 )D,O,-*
1 %uma sa&t menetap&an &e(an!&a 8a&tu SK, Pedoman/panduan, SPO
pen7elesaan peme(&saan %adoda!nost&, Iman!
Dan %adolo! Inte(6ensonal3 ) %*
AP 6.4
2 Dla&u&an penatatan dan e6aluas 8a&tu te(antum dlm lem4a( asl (adolo!,
pen7elesaan peme(&saan %adoda!nost&, Iman! tan!!al. am dte(ma dan &elau( asl
Dan %adolo! Inte(6ensonal3 )D,-*
" Dla&u&anpenatatandane6aluas8a&tupen7elesaanp te(antum dlm lem4a( asl (adolo!,
eme(&saanto)lat u!a, PA+3* )D,-* tan!!al. am dte(ma dan &elau( asl
1 Ada (e!ulas dan p(o!(am untu& pen!elolaan SPO pemela(aan alat (adolo!
pe(alatan pela7anan (adoda!nost&, man! dan
(adolo! nte(6ensonal )%I%* 7an! melput 4ut( a*
sampa den!an * d ma&sud dan tuuan3 ) %*
2 Ada 4u&t sta' 7an! te(lat mela&sana&an u 'un!s asl &unun!an te&ns te(smpan d alat
dan ddo&umentas&an3 )D,-*
" Ada 4u&t sta' 7an! te(lat mela&sana&an nspe&s
# Ada 4u&t sta' 7an! te(lat mela&sana&an
pemela(aan 4e(&ala dan ddo&umentas&an3 )D,-*
AP 6.5 $ Ada4u&tsta'7an!te(latmela&sana&an&al4e(as4e(&al
adan ddo&umentas&an3 )D,-*
> Ada da'ta( n6enta(s pe(alatan pela7anan lst n6enta(s alat (adlo!
)%I%* )lat u!a M5K3C, EP 2*3 )D3-*
 Ada4u&tpela&sanaanmonto(n!dantnda&ante(adap& lapo(an e6aluas te&ns
e!a!alan'un!salat dan ddo&umentas&an3 )D,-*
C Ada 4u&t pela&sanaan 4la te(ad p(oses pena(&an tda& ada
)(eall* dan ddo&umentas&an3 )D,-*
F Te(adap &e!atan a* sampa den!an * dalam &unun!an e6aluas 4e(&ala pe( # t
Ma&sud dan tuuan dla&u&an e6aluas 4e(&ala dan
tnda& lanut ) D,- *
1 %uma sa&t menetap&an 'lm 0:(a7 dan 4aan lan SPO pen!adaan 'lm 0:(a7
7an! dpe(lu&an )lat u!a M5K3$, EP 1*3 ) %*
2 Ada (e!ulas tentan! pen!elolaan lo!st& 5lm 0:(a7, SPO pen!elolaan lo!st&
(ea!ens, dan 4aan lann7a, te(masu& &onds 4la
te(ad &e&oson!an sesua pe(atu(an pe(undan!an3
)lat u!a M5K $ EP 2*3 ) %*
AP 6.6
" Semua 'lm 0:(a7 dsmpan dan d4e( la4el, se(ta peala4elan pd 'lm 0:(a7
ddst(4us sesua pedoman da( pem4uatn7a atau
nst(u&s pada &emasann7a )lat u!a M5K3$, EP 2*3
)D,O,-*
# Ada4u&tpela&sanaane6aluas/audtsemua(ea!en3 lapo(an audt (ea!en
)D,-*
1 %uma sa&t menetap&an p(o!(am mutu pela7anan SK, Pedoman/panduan, SPO
(adoda!nost&, man!, dan (adolo! nte(6ensonal
melput a* sampa den!an e* d ma&sud dan tuuan3
)lat u!a TK%S 11 *3 ) %*
2 Ada4u&tpela&sanaan6aldastesmetoda)D,-* 4u&u 6aldas
" Ada 4u&t pen!a8asan a(an asl peme(&saan
AP 6.7 man! ole sta' (adolo! 7an! &ompeten dan
4e(8enan3 )D,-*
# Ada4u&tpela&sanaan&o(e&sepat&ad&etemu&anmas lapo(an &o(e&s epat
ala3)D,-*
$ Ada 4u&t audt te(adap anta(a lan  'lm, &ont(as, lapo(an audt
&e(tas US@, a(an de6elope(, '0e(3 )D,-*
> Adado&umentasasldantnda&an&o(e&s3)D,-* 4u&t pelapo(an dan e6aluas
1 Ada 4u&t n atau se(t'&as (adoda!nost&, man! se(t'&at (adolo! (uu&an
dan (adolo! nte(6ensonal )%I%* (uu&an ) %*
2 Ada 4u&t pela&sanaan &ont(ol mutu pela7anan lapo(an mutu

)%I%* (uu&an3 )D,-*
" Ada Sta' 7an! 4e(tan!!un! a8a4 atas &ont(ol mutu 4u&u 6aldas asl (adolo! lua(
AP 6.8 da( pela7anan (adoda!nost&, man! dan (adolo!
nte(6ensonal )%I%* (uu&an, dan me(e6e8 asl
&ont(ol mutu )D,-*
# Lapo(an taunan asl &ont(ol mutu pela7anan lapo(an mutu taunan
)%I%* (uu&an dse(a&an &epada pmpnan (uma
sa&t untu& e6aluas &ont(a& &lns taunan )D*
PAP 1 1 %umasa&tmenetap&an(e!ulas4a!pmpnanuntpela SK, Pedoman/Panduan, SPO
7ananuntu&4e&e(a sama mem4e(&an p(oses asuan
se(a!am dan men!au pada pe(atu(an pe(undan!:
undan!an 7an! 4e(la&u3 ) %*
2 Asuanse(a!amd4e(&ansesuape(s7a(atansesua4ut 'o(m asuan
(a*sampaden!an e* pada ma&sud dan tuuan PAP 13
)D,-*
PAP 2 1 Ada (e!ulas 7an! men!atu( pela7anan dan asuan SK, panduan, SPO
te(nte!(as d dan anta(4e(4a!a unt pela7anan3 ) %*
2 %enanaasuandnte!(as&andand&oo(dnas&andd 'o(m ass asuan te(nte!(as

ananta(4e(4a!aunt pela7anan3 )lat u!a A%K 2, EP
"*3 )D,O,-*
" Pem4e(anasuandnte!(as&andand&oo(dnas&and 'o(m ass asuan te(nte!(as
dananta(4e(4a!aunt pela7anan3 )D,O,-*
# ;asl atau smpulan (apat da( tm PPA atau ds&us PPT
lan tentan! &e(asama ddo&umentas&an dalam
PPT3 )D,-*
PAP 231 1 Ada(e!ulasasuanuntu&setappasend(enana&anol SK, Pedoman/Panduan, SPO
edo&te(penan!!un! a8a4 pela7anan )DP=P*,
pe(a8at, dan PPA lann7a dalam 8a&tu 2# am
sesuda pasen masu& (a8at nap3 ) %*
2 %enana asuan d4uat untu& setap pasen dan 'o(m ass asuan te(nte!(as
datat ole PPA 7an! mem4e(&an asuan d (e&am
meds pasen3 )D,-*
" %enanaasuanpasente(nte!(asd4uatden!ansasa( pont2 dlm 'o(m ass asuan
an4e(dasa(atasdata asesmen a8al dan &e4utuan
pasen3 )D,-*
# %enana asuan de6aluas sea(a 4e(&ala sesua PPT, 'o(mul( ass ulan!
den!an &onds pasen, dmuta&(&an, atau d(e6s
ole tm PPA 4e(dasa( atas asesmen ulan!3 )D,-*
$ Pe(&em4an!an tap pasen de6aluas 4e(&ala dan TTD < nama dlm PPT
d4uat notas pada PPT
ole DP=P sesua den!an &e4utuan dan d6e('&as
a(an ole DP=P3 )D,-*
PAP 232 1 %umasa&tmenetap&an(e!ulastataa(apem4e(anns SK, Pedoman/Panduan, SPO
t(u&s3)%*
2 Inst(u&s d4e(&an an7a ole me(e&a 7an! &ompeten PPT, %KA
dan 4e(8enan!3 )lat
KKS "*3 )D,-*
" Pe(mntaan untu& peme(&saan la4o(ato(um dan 'o(m la4 < (adolo!
da!nost& man! a(us
dse(ta nd&as &ln& apa4la memnta asln7a
4e(upa nte(p(etas3 )D,-*
# Inst(u&sddo&umentas&andlo&aste(tentuddalam4e( PPT
&as(e&ammed&
pasen3 )D,-*
PA+ 23" 1 Ada(e!ulastentan!tnda&an&ln&danda!nost&se(tap SK, panduan, SPO
enatatann7ad (e&am meds3 ) %*
2 Sta'7an!memnta4ese(taapaalasandla&u&antnda&an SOAP PPT
datatd(e&am meds pasen3 )D*
" ;asltnda&andatatd(e&ammedspasen3)D* lem4a( asl dselp&an dlm %M, PPT
# Padapasen(a8atalan4ladla&u&antnda&anda!nost& 5o(m Ass, lst tnd&an n6as'
n6as'/4e(s&o
a(us dla&u&an asesmen se(ta penatatann7a dalam
(e&am meds3 )D,-*
PA+ 23# 1 Pasen dan &elua(!a d4e(&an n'o(mas tentan! asl 'o(m edu&as
asuan dan pen!o4atan3 )lat u!a ;PK 23131, EP 1*3
)D,-*
2 Pasen dan &elua(!a d4e(&an n'o(mas tentan! asl pont2 'o(m edu&as
asuan dan pen!o4atan 7! tda& da(ap&an3 )lat
u!a ;PK 23131, EP 2*3 )D,-*
PA+ " 1 Ada (e!ulas p(oses dent'&as pasen (s&o tn!! SK, Pedoman/Panduan, SPO
dan pela7anan (s&o tn!! sesua den!an populas
pasenn7a se(ta penetapan (s&o tam4aan 7an!
mun!&n 4e(pen!a(u pada pasen (s&o tn!! dan
pela7anan (s&o tn!!3 ) %*
2 Sta'dlatuntu&pem4e(anpela7ananpadapasen(s&o sosalsas
tn!!danpela7anan (s&o tn!!3 )lat MKI C31, EP "*3
)D,O,-*
" Ada 4u&t pela&sanaan pem4e(an pela7anan pada 'o(m (est
pasen (s&o tn!! dan pela7anan (s&o tn!!3 )lat
MKI C31, EP "*3 )D,O,-*
# Ada 4u&t pen!em4an!an pela7anan (s&o tn!! lapo(an mutu
dmasu&&an &e dalam p(o!(am penn!&atan mutu
(uma sa&t3 )D,-*
PA+ "31 1 Ada(e!ulaspela&sanaanea(l78a(nn!s7stem)E-S*3 SK, Pedoman/Panduan, SPO
) %*
2 Ada4u&tsta'&lnsdlatmen!!una&anea(l78a(nn!s7s sosalsas
tem)E-S*3)D,-*
" Ada 4u&t sta' &lns mampu mela&sana&an ea(l7 pen!san 'o(m E-S, PPT
8a(nn! s7stem )E-S*3
)D,- ,S*
# Te(sedapenatatanaslea(l78a(nn!s7stem)E-S*3 pont 'o(m E-S
)D,-*
PA+ "32 1 Ada (e!ulas pela7anan (esustas 7an! te(seda dan SK, Panduan, SPO
d4e(&an selama 2# am setap a( d selu(u a(ea
(uma sa&t, se(ta pe(alatan meds untu& (esustas
dan o4at untu& 4antuan dup dasa( te(standa(
sesua den!an &e4utuan populas pasen3 )lat PA+
", EP "*3) %*
2 Dselu(ua(ea(umasa&t4antuandupdasa(d4e(&an 8a8ana(a dan smulas

se!e(asaatd&enal ent antun!:pa(u dan tnda&
lanut d4e(&an &u(an! da( $ ment3 )-,S*
" St 'd4  l t l t  )D -* D&l t t 
PAP "3" 1 Ada(e!ulaspela7ananda(adanp(odu&da(amelput4 SK, Panduan, SPO
ut(1sampaden!an > pada ma&sud dan tuuan3 )lat
AP$311 EP 2*3 ) %*
2 Ada4u&tpela&sanaanp(osesmelput4ut(1*sampaden 'o(m pe(mntaan pela7anan da(a
!an>*padama&sud dan tuuan3 )D,-*
" Ada 4u&t sta' 7an! &ompeten dan 4e(8enan! e&lst monto(n! pela7anan da(a )TTD*
mela&sana&an pela7anan da(a dan p(odu& da(a
se(ta mela&u&an monto(n! dan e6aluas3 )lat AP
$311, EP 1*3 )D,-*
PAP "3# 1 Ada(e!ulasasuanpasenalat4antudupdasa(ataupa SK, panduan, SPO
sen&oma3)%*
2 Ada4u&tpela&sanaanasuanpasenden!analat4antu 'o(m
dupsesuaden!an
(e!ulas3 )D,-*3
" Ada4u&tpela&sanaanasuanpasen&omasesuaden!a 'o(m
n(e!ulas3)D,-*3
PA+ "3$ 1 Ada(e!ulassuanpasenpen7a&tmenula(danmmuno: SK, panduan, SPO

supp(essed3)%*3
2 Ada 4u&t pela&sanaan asuan pasen pen7a&t 'o(m IMS
menula( sesua den!an
(e!ulas3 )D,-*3
" Ada 4u&t pela&sanaan asuan pasen mmuno: 'o(m mmuno:supp(essed
supp(essed sesua den!an
(e!ulas3 )D,-*3
PAP "3> 1H" p(oses dalss
PAP "3 1 Ada(e!ulaspela7ananpen!!unaanalatpen!alan!)(e SK, panduan, SPO
st(ant*3)%*3
2 Ada 4u&t pela&sanaan pela7anan pen!!unaan alat 'o(mul(
pen!alan! )(est(ant*
" Ada4u&tdla&u&ane6aluaspasensea(a4e(&ala3)D,-* lapo(an e6aluas
PAP "3C 1 Ada(e!ulaspela7anan&ususte(adappasen7an!lem SK, panduan, SPO
a,lanutusa,ana&, dan 7an! den!an &ete(!antun!an
4antuan, se(ta populas 7an! 4e(s&o ds&sa dan
(s&o tn!! lann7a te(masu& pasen den!an (s&o
4unu d(3 ) %*
2 Ada 4u&t pela&sanaan asuan pasen 7an! lema 'o(m asuan ps &usus
dan lanut usa 7an! tda& mand( mene(ma asuan
" Ada4u&tpela&sanaanasuanpasenana&danana&den 'o(m asuan ps ana&
!an&ete(!antun!an sesua den!an (e!ulas3 )D,-*
# Ada 4u&t pela&sanaan asuan te(adap populas 'o(m asuan &e&e(asan

pasen den!an (s&o &e&e(asan dan (s&o tn!!
lann7a te(masu& pasen den!an (s&o 4unu d(
PAP "3F &emote(ap
PAP # 1 %uma sa&t menetap&an (e!ulas 7an! 4e(&atan SK, Panduan, SPO
den!an pela7anan !B3 ) %*
2 %uma sa&t men7eda&an ma&anan sesua den!an 'o(m !B
&e4utuan pasen3
)D,O,-*
" Ada 4u&t p(oses pemesanan ma&anan pasen sesua 'o(m !B
den!an status !B dan
&e4utuan pasen se(ta datat d (e&am meds3 )D,-*
# Ma&anan dsap&an dan dsmpan den!an o4se(6as dan 8a8ana(a, pa&n!an

men!u(an! (s&o &ontamnas dan ma&anan
pem4usu&an3 )O,-*
$ Dst(4us ma&anan dla&sana&an tepat 8a&tu sesua p(o&e( !B
den!an &e4utuan3
)D,O,-*
> &a&elua(!amem4a8ama&anan4a!pasen,me(e&ad4 'o(m edu&as !B
e(edu&astentan!
pem4atasan det pasen dan (s&o &ontamnas se(ta
pem4usu&an sesua
den!an (e!ulas3 )D,O,-,S*
 Ma&anan7an!d4a8a&elua(!aatauo(an!landsmpans SPO
ea(a4ena(untu&
mene!a &ontamnas3 )D,O,-*
PAP $ 1 %umasa&tmenetap&an(e!ulasuntu&te(ap!Bte(nte SK, Panduan, SPO
!(as3) %*
2 Ada4u&tpem4e(ante(ap!Bte(nte!(aspadapasen(s 'o(m ass asuan nut(s te(nte!(as
&onut(s3)D,-*
" Asuan!Bte(nte!(asmena&up(enana,pem4e(an,d pont2 'o(m ass asuan nut(s
anmonto(te(ap!B3
)D,-*
# E6aluas dan monto(n! te(ap !B datat d (e&am PPT
meds pasen3 )lat AP 2
EP 1*3 )D*
PAP > 1 %umasa&tmenetap&an(e!ulaspela7ananpasenuntu SK, Panduan, SPO
&men!atasn7e(3)%*
2 Pasen n7e( mene(ma pela7anan untu& men!atas 'o(m manaemen n7e(
n7e( sesua den!an
&e4utuan3 )D,-*
" Pasen dan &elua(!a d4e(&an edu&as tentan!
pela7anan untu& men!atas
n7e( sesua den!an lata( 4ela&an! a!ama, 4uda7a,
nla:nla pasen, dan
&elua(!a3 )D,-*
# Pasen dan &elua(!a d4e(&an edu&as tentan! 'o(m edu&as

&emun!&nan tm4uln7a n7e(
a&4at tnda&an 7an! te(enana, p(osedu(
peme(&saan, dan plan 7an!
te(seda untu& men!atas n7e(3 )D,-,S*
$ %uma sa&t mela&sana&an pelatan pela7anan D&lat manaemen n7e(
men!atas n7e( untu& sta'3
)D,-*
PAP  1 Ada (e!ulas asesmen a8al dan ulan! pasen dalam SK, Panduan, SPO
taap te(mnal melput 4ut( 1 sampa den!an F pada
ma&sud dan tuuan3 ) %*
2 Ada 4u&t s&(nn! dla&u&an pada pasen 7an! 'o(m s&(nnn! te(mnal
dputus&an den!an &onds a(apan dup 7an! &el
" Pasen dalam taap te(mnal dla&u&an asesmen a8al 'o(m ass te(mnal
dan asesmen ulan!3 )D,-*
# ;aslasesmenmenentu&anasuandanla7anan7an!d4 'o(m ass te(mnal
e(&an3)D,-*
$ Asuan dalam taap te(mnal mempe(at&an (asa pont2 'o(m ass te(mnal
n7e( pasen3 )lat u!a
;PK 232*3 )D,-*
PAP 31 1 %uma sa&t menetap&an (e!ulas pela7anan pasen SK, Panduan, SPO
dalam taap te(mnal melput 4ut( 1 sampa den!an
> pada ma&sud dan tuuan3 ) %*
2 Sta'dedu&astentan!&e4utuanun&pasendalamtaa sosalsas
pte(mnal3)D,-*
" Pela7anan pasen dalam taap te(mnal 'o(m ass te(mnal
mempe(at&an !eala, &onds, dan
&e4utuan &eseatan atas asl asesmen3 )lat PAP
13 EP 1*3 )D, -*
# Pela7ananpasendalamtaapte(mnalmempe(a&anu 'o(m ass te(mnal
pa7amen!atas(asa
n7e( pasen3 )lat u!a ;PK 232*3 )D,-*
$ Pela7anan pasen dalam taap te(mnal
mempe(at&an &e4utuan 4ops&o:
sosal, emosonal, 4uda7a, dan sp(tual3 )D,-*
> Pasendan&elua(!adl4at&andalam&eputusanasuant 'o(m penola&an DN%
e(masu&&eputusan
do not (esustate/DN%3 )lat u!a ;PK 2*3 )D,-*
PAB 1 1 %"#- +#*( "e$e(#*#$ )e%'#+ e'##$#$ SK, Pe!"#$/P#$%#$, SPO
#$e+(e+, +e)(# +e#+ "!e)#( #$ #'#" #$
"e"e$%- +(#$#) )!e+ +e)(# e)#(%)#$
e)%$#$ %$#$#$.   
2 Pe'##$#$ #$e+(e+, +e)(# +e#+ "!e)#( #$

#'#" #$ #e*%#(, )e%'#), #$ $#"#$ (e)+e#
%$(%* "e"e$%- *e&%(%-#$ #+e$, O,
3 Pe'##$#$#$e+(e+,+e)(#+e#+"!e)#(#$#'#"(
e)"#+%*'##$#$#$ e)'%*#$ %$(%*
*e##(#)%)#(#$ (e)+e# 24 #". O,
PAB 2 1 A# )e%'#+ )%"#- +#*( #$ "e$#(%) e'##$#$ SK, Pe!"#$/P#$%#$, SPO
#$e+(e+, +e)(# +e#+ "!e)#( #$ #'#" +e)##"
 +e'%)%- )%"#- +#*( '-#( PAP 1. EP 1 #$
&e)##  &##- (#$%$ ##& +e!)#$ !*(e)
#$e+(e+ +e+%# e$#$ e)#(%)#$ e)%$#$#$.
'-#( TKS 5.  
2 A# &%* e$#$%$ ##& e'##$#$ #$e+(e+ &e'%" (e)'#*+#$#

%$(%* "e$e"&#$*#$, "e'#*+#$#*#$, #$
"e$## )e%'#+ +ee) &%) 1 +#"# e$#$ 4
## "#*+% #$ (%%#$. D
3 A#&%*e$#$%$##&"e$#'#$*#$)!)#"e
$e$#'#$"%(%.D.
4 A# &%* e'#*+#$##$ +%e):+ #$ e:#'%#+
e'#*+#$##$ e'##$#$
#$e+(e+, +e)(# +e#+ "!e)#( #$ #'#" 
+e'%)%- )%"#- +#*(. D,
PAB 2.1 1 %"#- +#*( "e$e(#*#$ )!)#" "%(% #$ SK, Pe!"#$/P#$%#$, SPO
*e+e'#"#(#$ #+e$ #'#" e'##$#$ #$e+(e+,
+e)(# +e#+ "!e)#( #$ #'#". '-#( PMKP 2.1. 

2 A# &%* "!$(!)$ #$ e:#'%#+ e'#*+#$##$ =)!++ =-e=* %'#$ !)"
#+e+"e$ )#+e#+ #$ )# )#+e#+/#$e+(e+
#$e+(e+. D,
3 A# &%* "!$(!)$ #$ e:#'%#+ )!+e+

"!$(!)$ +(#(%+ ;+!'!+ +e'#"#
#$e+(e+. D,
4 A# &%* "!$(!)$ #$ e:#'%#+ )!+e+

"!$(!)$ +e)(# )!+e+ e"%'-#$
#$e+(e+ #$ +e#+ #'#". D,
5 A#&%*"!$(!)$#$e:#'%#+e:#'%#+%'#$&'#(e
)#*!$:e)+$#*#$
#) '!*#'/)e!$#' *e e$e)#'. D,
6 A#&%*e'#*+#$##$)!)#""%(%#$*e+e'#"#(# &'" '#*+#$#*#$, *!'#&!)#+ $ PMKP

$#+e$#'#"#$e+(e+,
+e)(# +e#+ "!e)#( #$ #'#" #$
$(e)#+*#$ e$#$ )!)#" "%(% )%"#- +#*(.
'-#( PMKP 2.1. D,
PAB 3 1 A#)e%'#+)%"#-+#*(#$"e$e(#*#$e"&e)#$ SK, Pe!"#$/P#$%#$/SPO

+e#+#$+e)##"  +e"%# (e"#(  )%"#-
+#*( +e+%# e$#$ e)#(%)#$ e)%$#$#$
(e(#*#$ #$ '#*+#$#*#$ +e+%# e$#$ e'e"e$
# +#"# e$#$  +ee) #$ $#(#*#$ ##
"#*+% #$ (%%#$ PAB 3.  
2 A# &%* e'#*+#$##$ +e#+ +e+%# e$#$ !)"%') +e#+

)e%'#+ #$ (e(#*#$. D,O,
3 Pe)#'#(#$ e"e)e$+ (e)+e# #$ e)%$#*#$ ()!'e e"e)e$=, =)!++ =-e=* + +e+%#
+e+%# e$#$ e$+ +e#+, %+#, #$ *!$+ PKPO
#+e$. D,O
4 S(# #$ (e)'#- #$ &e)e$#'#"#$ #'#" +e);*#( A<LS/ATLS, *!'#&!)#+ KKS
"e"&e)*#$ &#$(%#$ -% '#$%( #:#$=e -#)%+
+e'#'% (e)+e# #$ +## +e'#"# $#*#$ +e#+
*e)#*#$. D,O,
PAB 3.1 1 P)!e+!$#' e"&e) #+%-#$ PPA #$ SK, Pe!"#$/P#$%#$/SPO
&e)(#$%$ ##& "e"&e)*#$ +e#+ ##'#-
!)#$ #$ *!"e(e$ #'#" -#' #'$ +e*( &%)
1 +#"# e$#$ 4 ## "#*+% #$ (%%#$ PAB
3.1.  
2 P)!e+!$#' e"&e) #+%-#$ PPA #$ SK, Pe!"#$/P#$%#$/SPO

&e)(#$%$ ##& "e'#*%*#$ e"#$(#%#$
+e'#"# &e)*#$ +e#+ ##'#- !)#$ #$
*!"e(e$ #'#" -#' #'$ +e*( &%) 5 +#"#
e$#$ 8 ## "#*+% #$ (%%#$ PAB 3.1.  
3 K!"e(e$+ +e"%# +(# #$ (e)'&#( #'#" +e#+ <V, +e);*#(

(e)=#(#( #'#" !*%"e$ *ee###$. '-#( KKS
5. D,
PAB 3.2 1 D'#*%*#$#+e+"e$)#+e#+#$=#(#(#'#")e*#" =)!++ =-e=* %'#$

"e+#$+e*%)#$ *%)#$$# &e)+*#$ &%) #
+#"# e$#$ e ## "#*+% #$ (%%#$ PAB 3.2
%$(%* e:#'%#+ )+*! #$ *e'##*#$ $#*#$ +e#+
&# #+e$ + e+%# e$#$ )e%'#+ #$ (e(#*#$
!'e- )%"#- +#*(. '-#( AP 14. D,
2 Se!)#$ #$ *!"e(e$ "e'#*%*#$ e"#$(#%#$ =-e=*'+( "!$(!)$

#+e$ +e'#"# +e#+ #$ "e$=#(#( -#+' "!$(!)
#'#" )e*#" "e+. D,
3 K)(e)# e"%'-#$ %$#*#$ #$ =-e=*'+( 

!*%"e$(#+*#$ +e(e'#- +e'e+# $#*#$ +e#+.
D,
PAB 3.3 1 P#+e$ #$ #(#% *e'%#)# #(#% -#* '#$ #$ SIA, SPO :+( )e +e#+, "!$(!)$ >
&e)e$#$ #$ "e"&e)*#$ *e%(%+#$ e'#!)#$ "%(%
e'#+*#$ (e$(#$ )+*!, *e%$(%$#$, #$
#'(e)$# (e$(#$ $#*#$ +e#+.  D,
2 P#+e$ #$ #(#% *e'%#)# #(#% -#* '#$ #$ SIA, SPO :+( )e +e#+, "!$(!)$ >
&e)e$#$ &e) e%*#+ (e$(#$ e"&e)#$ e'#!)#$ "%(%
#$#'e+ #+=#$#*#$ +e#+. D,
3 D!*(e) +e+#'+ #$e+(e+ "e'#*+#$#*#$ e%*#+ SIA, SPO :+( )e +e#+, "!$(!)$ >
#$ "e$!*%"e$(#+*#$. D, e'#!)#$ "%(%
PAB 4 1 A+e+"e$)# SPO :+( )e#$e+(e+, <PPT,"!$(!)$
#$e+(e+'#*%*#$%$(%*+e##+e$#$#*#$!e %'#$
)#+.'-#( %# AP 1. D,
2 ?#+'#+e+"e$!*%"e$(#+*#$#'#")e*#""e+ M
#+e$.D,
PAB 4.1 1 A+e+"e$)#$%*+'#*%*#$%$(%*+e##+e$+e& =-e=*'+( #$ SPO, "!$(!)$

e'%"'#*%*#$$%*+. D,
2 ?#+'#+e+"e$!*%"e$(#+*#$#'#")e*#""e+ M
#+e$.D,
PAB 5 1 A# )e%'#+ e'##$#$ #$e+(e+ +e# #+e$ #$ SK, Pe!"#$/P#$%#$/SPO
)e$=#$#*#$ #$ !*%"e$(#+*#$.  
2 O&#(!&#( #$e+(e+, !++, #$ )%(e +e)(# (e*$* '#!)#$ #$e+(e+
#$e+(e+ !*%"e$(#+*#$  )e*#" "e+ #+e$.
D,
3 D!*(e)+e+#'+#$e+(e+#$e)##(#$"e$#" !)" #$e+(e+

$/e$#(##$e+(e+(%'+ #'#" !)" #$e+(e+.
D,
PAB 5.1 1 P#+e$ #$ #(#% *e'%#)# #(#% -#* '#$ #$ SIA
&e)e$#$ #$ "e"&e)*#$ *e%(%+#$
e'#+*#$ (e$(#$ )+*!, *e%$(%$#$, #$ %#
#'(e)$# $#*#$ #$e+(e+. D,
2 P#+e$ #$ #(#% *e'%#)# #(#% -#* '#$ #$ $!)"e =!$+e$( #$ !)"%') e%*#+,
&e)e$#$ &e)*#$ e%*#+ e"&e)#$ #$#'e+ &e'%" ##
#+=#$#*#$ #$e+(e+. D,
3 D!*(e) +e+#'+ #$e+(e+ "e'#*+#$#*#$ )!+e+ SPO #$ M, "!$(!)$ e'#*+#$##$
e%*#+ #$ %# "e$!*%"e$(#+*#$$#. ,D
PAB 6 1 A# )e%'#+ e$+ #$ )e*%e$+ e"#$(#%#$ SK, Pe!"#$/P#$%#$/SPO
+e'#"# #$e+(e+ #$ !e)#+ '#*%*#$ &e)#+#)
#(#+ +(#(%+ #+e$ )##$e+(e+, "e(!e #$e+(e+
#$ #*#, #$ $#*#$ !e)#+ #$ '#*%*#$.
 
2 Pe"#$(#%#$ +(#(%+ ;+!'!+ #+e$ +e+%# e$#$ !)" #$e+(e+

#$%#$ )#** *'$+. D,
3 ?#+'"!$(!)$=#(#(!)"#$e+(e+.D,
PAB 6.1 1 P#+e$ $#-*#$ #) )%#$ e"%'-#$ #(#% *# SK, Pe!"#$/#$%#$, SPO
"!$(!)$ e"%'-#$ -e$*#$ +e+%# e$#$
#'(e)$# &%) 1 +#"# e$#$ 3 ## "#*+%
#$ (%%#$ PAB 6.1.  
2 #*(%"#+%*)%#$e"%'-#$#$$#-*#$#)) !)" #$e+(e+, 'e"&#)#$ "!$(!)$

%#$e"%'-#$=#(#( #'#" !)" #$e+(e+.
D,O,
3 P#+e$ "!$(!) #'#" "#+# e"%'-#$ #+=# !)" #$e+(e+, 'e"&#)#$ "!$(!)$
#$e+(e+ +e+%# e$#$ )e%'#+ )%"#- +#*(.
D,O,
4 ?#+'"!$(!)$=#(#(!)"#$e+(e+.D
PAB 7 1 A#)e%'#+#+%-#$+e##+e$&e#-)e$=#$#*#$ SK, Pe!"#$/#$%#$, SPO
&e)#+#)#(#+$!)"#+ #) -#+' #+e+"e$.  
2 D#$!++ )#!e)#+ #$ )e$=#$# !e)#+ =#(#(  M SOAP, <PPT &e'%" '#*%*#$
)e*#" "e* #+e$ !'e- !*(e) e$#$%$
##& e'##$#$ DP@P +e&e'%" !e)#+ "%'#.
D,
3 ?#+'#+e+"e$#$%$#*#$%$(%*"e$e$(%*#$)e$ M SOAP, <PPT &e'%" '#*%*#$

=#$#!e)#+=#(#(!'e- !*(e) e$#$%$ ##&
e'##$#$ DP@P  )e*#" "e+ #+e$ +e&e'%"
!e)#+ "%'#. '-#( %# AP 1.2.1 AP 1.3.1.
D,
PAB 7.1 1 P#+e$, *e'%#)#, #$ "e)e*# #$ "e"%(%+*#$ SIO
&e)*#$ e%*#+ (e$(#$ )+*!, "#$##(,
*!"'*#+, +e)(# #"#* #$ #'(e)$#
)!+e%)/(e*$* (e)*#( e$#$ )e$=#$# !e)#+.
D,
2 E%*#+ "e"%#( *e&%(%-#$, )+*!, "#$##(, #$ SIO (#"&#-*#$ !$( ()#$+%+
#'(e)$# e$%$##$ #)#- #$ )!%* #)#-.
D,
3 E%*#+ '#*%*#$ !'e- !*(e) e$#$%$ ##& TTD DP@P  !)" SIO, "!$(!)$
e'##$#$ DP@P #$ =#(#( ## &##$
e"&e)#$ $!)"#+ #'#" !)" e)+e(%%#$
$#*#$ *e!*(e)#$. D,
PAB 7.2 1 A#)e%'#+'#!)#$!e)#+#$"e'%+e*%)#$ SPO

*%)#$$#&%)1+#"# e$#$ 8 ## "#*+%
#$ (%%#$.  
2 A#&%*'#!)#$!e)#+"e"%#(#'$+e*(&%)1 !)" '#!)#$ !e)#+ , M

+#"#e$#$8## "#*+% #$ (%%#$ +e)(#
=#(#( ## !)" #$ (e(#*#$ )%"#- +#*(
(e)+e# +ee)# +e(e'#- !e)#+ +e'e+# #$
+e&e'%" #+e$ $#- *e #)e# '#$ %$(%* #+%-#$
&#+#. D,
3 L#!)#$ !e)#+ ##( =#(#(  #)e# #+%-#$ !)" '#!)#$ !e)#+ , M

$(e$+ '#$%(#$. D,
PAB 7.3 1 )e%'#+ )e$=#$# #+%-#$ #+=#!e)#+ &%#( !'e- SK, Pe!"#$/#$%#$, SPO
DP@P, e)##(, #$ PPA '#$$# %(* "e"e$%-
*e&%(%-#$ +ee)# ##+e$ ##+=#!e)#+  
2 A#&%*e'#*+#$##$)e$=#$##+%-#$#+=#!e)#+ M, !)" !+( !e)#+
=#(#()e*#""e+ #+e$ #'#" #*(% 24 #"
!'e- !*(e) e$#$%$ ##& e'##$#$ DP@P
#(#% :e);*#+ !'e- !*(e) e$#$%$ ##&
e'##$#$ DP@P &'# (%'+ !'e- !*(e) &e#- 
e'e#+*#$. D,
3 A# &%* e'#*+#$##$ )e$=#$# #+%-#$ <PPT

#+=#!e)#+ (e)"#+%* )e$=#$# #+%-#$ "e+,
*ee)##(#$, #$ PPA '#$$# &e)#+#) #(#+
*e&%(%-#$ #+e$. D,O,
4 A# &%* e'#*+#$##$ )e$=#$# #+%-#$

#+=#!e)#+ %&#- &e)#+#) #(#+ #+e+"e$ %'#$
#+e$. D,O,
PAB 7.4 1 A# )e%'#+ #$ "e'% &%) # +#"# e$#$ SK, Pe!"#$/#$%#$, SPO
- ## "#*+% #$ (%%#$.  
2 A###)#'#"'#$#$%$#*#$)%"#-+#*(. '+( I"'#$
D,
3 B'# "'#$ #$ #+#$ '#*%*#$ e$#)*#$ <PPT ## +##( *!$()!' !'
*e"&#' )e=#'' ## &%*
)%"#- +#*( ##( "e'#*%*#$ (e'%+%) (e)-##
#+e$ (e)*#(. D,O,
4 A#&%*#'#"'#$"#+%**#$#'#")!)(#+"!$ +=*e) "'#$

(!)$%$Ce)*#(.D,
PAB 8 1 %"#-+#*("e$e(#*#$e$+e'##$#$&e#-#$ #$%#$ #$ SK e'##$#$ &e#-
##('#*+#$#*#$.
2 K#"#)!e)#+"e"e$%-e)+#)#(#$(e$(#$e$#( Pe)&#*#$ )%#$#$ #$ #'%) *e'%#)
%)#$!$#&e)#+#)#(#+ $*#( +(e)'(#+ )%#$#$ "#+%* OK
+e+%# e$#$ e)#(%)#$ e)%$#$%$#$#$.
O,
3 K#"#) !e)#+ "e"e$%- e)+#)#(#$ #'%) "#+%*

&#)#$&#)#$ +(e)' -#)%+
(e)+#- #) #'%) *e'%#) &#)#$ #$ #*##$ *!(!).
O,
4 K#"#) !e)#+ "e"e$%- e)+#)#(#$ *!)!)
+(e)' +#-*#$/#* &!'e-
&e)+'#$#$ #'%)$# e$#$ *!)!) *!(!). O,
PAB 8.1 1 %"#- +#*( "e$e(#*#$ )!)#" "%(% #$ (e)(%#$ '" #$%#$
*e+e'#"#(#$ #+e$ #'#" e'##$#$ &e#-.  &e#-,*!'#&!)#+ PMKP
2 A#&%*"!$(!)$#$e:#'%#+e'#*+#$##$#+e+" :+( )# &e#- M, "!$(!)$
e$)#&e#-.D,
3 A# &%* "!$(!)$ #$ e:#'%#+ e'#*+#$##$ !)" +(e "#)*$
e$#$##$ '!*#+ !e)#+.
D,
4 A#&%*"!$(!)$#$e:#'%#+e'#*+#$##$+%)= M #$ SS<

#'+#e(=-e=*L+('-#(
%# SKP 4. D.
5 A# &%* "!$(!)$ #$ e:#'%#+ e"#$(#%#$ '#!)#$ &e#-

+*)e#$+ #$!++ )e #$
!+!e)#+. D,
6 P)!)#" "%(% e'##$#$ &e#- $(e)#+*#$ '#!)#$ "%(% *e *!"(e "%(%, &e'%"
e$#$ )!)#" "%(% )%"#- (e)'#*+#$#
+#*( '-#( PMKP 2.1 . D,
PKPO 1 1 Ada (e!ulas o(!ansas 7an! men!elola pela7anan SK, Pedoman/panduan, SPO
&e'a(masan dan pen!!unaan o4at 7an! men7elu(u atau
men!a(a&an semua taapan pela7anan &e'a(masan se(ta
pen!!unaan o4at 7an! aman sesua den!an pe(atu(an
pe(undan!:undan!an3 ) %*
2 Ada 4u&t selu(u apote&e( meml& Bn dan mela&u&an ST% dan 'o(m s(eenn! d TTD ole
supe(6s sesua den!an penu!asann7a3 )D,-* apote&e(
" Ada4u&tpela&sanaanse&u(an!: lapo(an e6aluas
&u(an!n7asatu&aanpela7anan&e'a(masan dan
pen!!unaan o4at 7an! ddo&umentas&an selama 12 4ulan
te(a&(3 )D,-*
# Ada 4u&t sum4e( n'o(mas o4at 7an! tepat, te(&n, dan MIMS
selalu te(seda 4a!
semua 7an! te(l4at dalam pen!!unaan o4at3 )D,O,-*
$ Te(la&sana pelapo(an &esalaan pen!!unaan o4at sesua lapo(an monto(n! dlm 4u&u
den!an pe(atu(an
pe(undan!:undan!an3 )D,-*
> Te(la&sana tnda& lanut te(adap &esalaan pen!!unaan lapo(an e6aluas dlm 4u&u monto(n!
o4at untu&
mempe(4a& sstem manaemen dan pen!!unaan o4at
sesua den!an pe(atu(an pe(undan!:undan!an3 )D,-*
PKPO 2 1 Ada(e!ulaso(!ansas7an!men7usun'o(mula(um(umasa& SK, Pedoman K5T
t4e(dasa(atas &(te(a 7an! dsusun sea(a &ola4o(at'
sesua den!an pe(atu(an pe(undan!: undan!an3 )%*
2 Ada 4u&t pela&sanaan apa4la ada o4at 7an! 4a(u 'o(m monto(n! pen!!unaan o4at 4a(u dan
dtam4a&an dalam 'o(mula(um ma&a ada p(oses untu& KTD
memantau 4a!amana pen!!unaan o4at te(se4ut dan 4la
te(ad e'e& o4at 7an! tda& da(ap&an, e'e& sampn! se(ta
medaton e((o(3 )D,-*
" Ada4u&tmplementasuntu&memantau&epatuante(adap'o lapo(an op7 (esep

(mula(um4a& da( pe(sedaan maupun pen!!unaan7a3
)D,-*
# Ada 4u&t pela&sanaan 'o(mula(um se&u(an!:&u(an!n7a lapo(an e6aluas
d&a setaun se&al 4e(dasa( atas n'o(mas tentan!
&eamanan dan e'e&t6tas3 )D,-*
PKPO 231 1 Ada (e!ulas pen!adaan sedaan 'a(mas, alat &eseatan, SK, Pedoman/panduan, SPO
dan 4aan meds a4s pa&a 7an! aman, 4e(mutu,
4e(man'aat, se(ta 4e(&asat sesua den!an pe(atu(an
pe(undan!:undan!an3 )lat u!a TK%S *3 ) %*
2 Ada 4u&t 4a8a manaemen (anta pen!adaan )suppl7 da!(am alu(
an mana!ement* dla&sana&an sesua den!an pe(atu(an
pe(undan!:undan!an3 )lat u!a TK%S 31*
" Ada4u&tpen!adaano4at4e(dasa(atas&ont(a&3 tda& mela&u&an, pen!adaaan sesua d!n
)latu!aTK%S* &onsums
PKPO 23131 1 Ada(e!ulaspen!adaan4lasedaan'a(mas,alat&eseatan,da SK, Pedoman/panduan, SPO
n4aanmeds a4s pa&a tda& ada dalam sto& atau tda&
te(seda saat d4utu&an3 ) %*
2 Ada 4u&t pem4e(tauan &epada sta' meds se(ta sa(an 'o(m pen!antan
su4sttusn7a3 )D,-*
" Ada4u&t4a8asta'memaamdanmematu(e!ulaste(se4u lapo(an monto(n! dan e6aluas
t3)D,-*
PKPO " 1 Ada (e!ulas tentan! pen!atu(an pen7mpanan sedaan SK, Pedoman/panduan, SPO
'a(mas, alat &eseatan, dan 4aan meds a4s pa&a 7an!
4a&, 4ena(, dan aman3 ) %*
2 Ada4u&to4atdanBat&ma7an!d!una&anuntu&mempe(sap& pela4elan o4at dan Bat &ma, lapo(an mutu
ano4atd4e( la4el 7an! te(d( atas s/nama o4at, tan!!al penempelan la4el
&adalua(sa, dan pe(n!atan &usus3 )lat u!a M5K $ EP
>*3 )O,-*
" Ada4u&tmplementasp(osespen7mpanano4at7an!tepata! lapo(an monto(n! dan e6aluas
a(&ondso4at tetap sta4l, te(masu& o4at 7an! dsmpan d
lua( nstalas 'a(mas3 )D,-*
# Ada 4u&t pela&sanaan dla&u&an supe(6s sea(a te(atu( TTD apote&e(/ass apote&e( d 'o(m
ole apote&e( untu& memast&an pen7mpanan o4at monto(n! dan e6aluas
dla&u&an den!an 4a&3 )D,-*
$ Ada4u&tpela&sanaano4atdlndun!da(&elan!anse(tapen lapo(an monto(n! sto& 4e(&as dan sstem
u(andsemua tempat pen7mpanan dan pela7anan3 )D,-* (us sama
PKPO "31 1 Ada(e!ulaspen!atu(antata&elola4aan4e(4aa7a,se(tao4a SK, Pedoman/panduan, SPO

tna(&ot&adan ps&ot(op&a 7an! 4a&, 4ena(, dan aman
sesua den!an pe(atu(an pe(undan!: undan!an3 ) %*
2 Ada 4u&t pen7mpanan 4aan 4e(4aa7a 7an! 4a&, 4ena(, o4se(6as dan 8a8ana(a
dan aman sesua den!an e!ulas3 )O,-*
" Ada4u&tpen7mpanano4atna(&ot&ase(taps&ot(op&a7an!4
a&,4ena(,dan aman sesua den!an (e!ulas3 )O,-*
# Ada 4u&t pelapo(an o4at na(&ot&a se(ta ps&ot(op&a lapo(an SIPNAP onlne pe( 4ulan dan &a(tu
sea(a a&u(at sesua den!an pe(atu(an dan pe(undan!: sto& a(an, lapo(an &e Dnas
undan!an3 )D,-*
PKPO "32 1 Ada (e!ulas (uma sa&t tentan! p(oses la(an!an SK, Pedoman/Panduan, SPO
men7mpan ele&t(olt &onsent(at d tempat (a8at nap
&eual 4la d4utu&an sea(a &ln& dan apa4la te(pa&sa
dsmpan d a(ea (a8at nap a(us datu( &eamanann7a
untu& men!nda( &esalaan3 )lat u!a SKP "31*3 ) %*
2 Ada4u&tpen7mpananele&t(olt&onsent(at7an!4a&,4ena(,da o4se(6as dan 8a8ana(a

namansesua den!an e!ulas3 )O,-*
" Ele&t(olt &onsent(at d4e( la4el o4at 7an! a(us pela4elan pd ele&t(olt &onsent(at
d8aspada )! ale(t* sesua den!an (e!ulas3 )O,-*
PKPO "3" 1 Ada(e!ulaspen!atu(anpen7mpanano4atden!an&etentuan& SK, Pedoman/Panduan, SPO

ususmelput 4ut( 1 sampa den!an $ pada ma&sud dan
tuuan3 ) %*
2 Ada 4u&t pen7mpanan p(odu& nut(s 7an! 4a&, 4ena(, dan o4se(6as dan 8a8ana(a
aman sesua den!an (e!ulas3 )lat u!a PAP #*3 )O,-*
" Ada4u&tpen7mpanano4atdan4aan(adoa&t'7an!4a&,4en
a(,danaman sesua den!an (e!ulas3 )O,-*
# Ada 4u&t pen7mpanan o4at 7an! d4a8a pasen se4elum
(a8at nap 7an! 4a&, 4ena(, dan aman sesua den!an
(e!ulas3 )O,-*
$ Ada4u&tpen7mpanano4atp(o!(amatau4antuanpeme(nta/
pa&lan7an! 4a&, 4ena(, dan aman sesua den!an
(e!ulas3 )O,-*
> Ada4u&tpen7mpanano4at7an!d!una&anuntu&peneltan7a
n!4a&,4ena(, dan aman sesua den!an (e!ulas3 )O,-*
PKPO "3# 1 Ada (e!ulas pen!elolaan o4at eme(!ens 7an! te(seda d SK, pedoman/Panduan, SPO
unt:unt la7anan a!a( dapat se!e(a dpa&a untu&
memenu &e4utuan da(u(at se(ta upa7a pemela(aan
dan pen!amanan da( &emun!&nan penu(an dan
&elan!an3 )lat u!a TK%S 3*3 ) %*
2 Ada4u&tpe(sedaano4ateme(!enslen!&apdansappa&a3 lst o4at d t(ol7 eme(!en7

)D,O,-*
" Ada 4u&t pela&sanaan supe(6s te(adap pen7mpanan TTD apote&e( d lst o4at dan 'o(m 4u&a
o4at eme(!ens dan se!e(a d!ant apa4la dpa&a, tutup o4at
&adalu8a(sa, atau (usa&3 )D,O,-*
PKPO "3$ 1 Ada(e!ulaspena(&an&em4al)(eall*danpemusnaanseda SK, pedoman/Panduan, SPO
an'a(mas,alat &eseatan, dan 4aan meds a4s pa&a
7an! tda& la7a& pa&a &a(ena (usa&, mutu su4standa(d,
atau &adalu8a(sa3 ) %*
2 Ada4u&tpela&sanaanpena(&an&em4al)(eall*sesuaden!a 4u&u ED/(usa& dan pelapo(an pe( 4ulan,
n(e!ulas7an! dtetap&an3 )D,-* 4e(ta aa(a pemusnaan 7! d TTD ole
Dn&es dan POM
" Ada 4u&t pela&sanaan pemusnaan sesua den!an
(e!ulas 7an! dtetap&an3 )D,-*
PKPO # 1 Ada (e!ulas pe(esepan/pe(mntaan o4at dan nst(u&s SK, pedoman/Panduan, SPO
pen!o4atan sea(a 4ena(, len!&ap, dan te(4aa, se(ta
menetap&an sta' meds 7an! &ompeten dan 4e(8enan!
untu& mela&u&an pe(esepan/pe(mntaan o4at dan nst(u&s
pen!o4atan3 )lat u!a PAP 232 EP 1H AP " EP 1H dan SKP
2 EP 1*3 ) %*
2 Ada 4u&t pe(esepan/pe(mntaan o4at dan nst(u&s 'o(m spesmen dan tulsan do&te(
pen!o4atan dla&sana&an ole sta' meds 7an! &ompeten
se(ta 4e(8enan!3 )D,O,-*
" Ada4u&tpela&sanaanapote&e(mela&u&an(e&onslaso4atpa 'o(m (e&onslas
dasaatpasen masu&, pnda unt pela7anan, dan se4elum
pulan!3 )D,-*
# %e&ammedsmemuat(8a7atpen!!unaano4atpasen3)D,O* SOAP/PPT
PKPO #31 1 Ada (e!ulas s7a(at elemen (esep len!&ap 7an! melput SK, pedoman/Panduan, SPO
4ut( 1 sampa den!an  pada ma&sud dan tuuan se(ta
penetapan dan pene(apan lan!&a lan!&a untu&
pen!elolaan pe(esepan/pe(mntaan o4at, nst(u&s
pen!o4atan 7an! tda& 4ena(, tda& len!&ap, dan tda&
te(4aa a!a( al te(se4ut tda& te(ulan! &em4al3 ) %*
2 Ada 4u&t pela&sanaan e6aluas s7a(at elemen (esep 'o(m s(eenn! (esep
len!&ap 7an! melput 4ut( 1 sampa den!an  pada
ma&sud dan tuuan3 )D,-*
" Ada 4u&t pela&sanaan p(oses pen!elolaan (esep 7an! 'o(m s(eenn! (esep
tda& 4ena(, tda& len!&ap, dan tda& te(4aa3 )D,-*
# Ada 4u&t pela&sanaan p(oses untu& men!elola (esep te(tuls dlm PPT
&usus, sepe(t da(u(at, standn! o(de(, 4e(ent automats
)automat stop o(de(*, tape(n!, dan lann7a3 )D,-*
PKPO #32 1 Ada da'ta( sta' meds 7an! &ompeten dan 4e(8enan! da'ta( lst do&te( < ST%
mem4uat atau menuls (esep 7an! te(seda d semua unt
pela7anan3 )D*
2 Ada 4u&t pela&sanaan (uma sa&t menetap&an dan SK, pedoman/Panduan, SPO
mela&sana&an p(oses untu& mem4atas &a dpe(lu&an
umla (esep atau umla pemesanan o4at 7an! dapat
dla&u&an ole sta' meds 7an! d4e( &e8enan!an3 )lat
u!a KKS 1J EP 1*3 ) %*
" Ada 4u&t sta' meds 7an! &ompeten dan 4e(8enan! ST% do&te(
mem4uat atau menuls (esep atau memesan o4at d&enal
dan d&etau ole unt la7anan 'a(mas atau ole lann7a
7an! men7alu(&an o4at3 )D*
PKPO #3" 1 Ada 4u&t pela&sanaan o4at 7an! d4e(&an datat dalam PPT
satu da'ta( d (e&am meds untu& setap pasen 4e(s
denttas pasen, nama o4at, doss, (ute pem4e(an, 8a&tu
pem4e(an, nama do&te( dan &ete(an!an 4la pe(lu tape(n!
o'', tt(as, dan (entan! doss3 )D*
2 Ada 4u&t pela&sanaan da'ta( te(se4ut d atas dsmpan PPT, %esume Pulan!
dalam (e&am meds pasen dan men7e(ta pasen &et&a
pasen dpnda&an3 Salnan da'ta( te(se4ut dse(a&an
&epada pasen saat pulan!3 )D*
PKPO $ 1 Ada (e!ulas pen7apan dan pen7e(aan o4at 7an! sesua SK, pedoman/Panduan, SPO
den!an pe(atu(an pe(undan!:undan!an dan p(a&t& p(o'es3
) %*
2 Ada 4u&t pela&sanaan sta' 7an! men7ap&an p(odu& ste(l se(t'&at
dlat, memaam, se(ta memp(a&t&&an p(nsp pen7apan
o4at dan te&n& asept& )lat u!a
PPI 33*3 )D,-*
" Ada4u&tpela&sanaanpenampu(ano4at&emote(apdla&u&a
nsesuaden!an p(a&t& p(o'es3 )lat u!a PPI 33*3 )O,-*
# Ada 4u&t penampu(an o4at nt(a6ena, epdu(al, dan nut(s o4se(6as dan 8a8ana(a
pa(ente(al se(ta pen!emasan &em4al o4at sunt& dla&u&an
sesua den!an (a&t& p(o'es3 )O,-*
PKPO $31 1 Ada (e!ulas penetapan sstem 7an! se(a!am untu& SK, Pedoman/panduan, SPO
pen7apan dan pen7e(aan o4at3 ) %*
2 Ada 4u&t pela&sanaan p(oses pen!&aan (esep 7an! 'o(m s(eenn! (esep
melput 4ut( 1 sampa den!an  pada ma&sud dan tuuan3
)D,-*
" Setelape(sapan,o4atd4e(la4elmelputdenttaspasen,na pela4elan et&et ele&t(&
mao4at,doss atau &onsent(as, a(a pema&aan, 8a&tu
pem4e(an, tan!!al dsap&an, dan tan!!al &adalua(sa3
)D,O,-*
# Ada 4u&t pela&sanaan telaa o4at melput 4ut( 1 sampa 'o(m s(eenn! (esep
den!an $ pada ma&sud dan tuuan3 )D,-*
$ Ada 4u&t pela&sanaan pen7e(aan o4at dalam 4entu& TTD pem4e( dan pene(ma o4at d 'o(m
7an! sap d4e(&an3 )D,-* (esep
> Ada4u&tpen7e(aano4attepat8a&tu3)D,O,-* lapo(an &etepatan 8a&tu
PKPO > 1 Ada penetapan sta' &lns 7an! &ompeten dan 4e(8enan! SK lst do&te(
untu& mem4e(&an o4at te(masu& pem4atasann7a3 ) %*
2 Ada 4u&t pela&sanaan pem4e(an o4at ole sta' &lns 7an! SIP do&te(
&ompeten dan 4e(8enan! sesua den!an su(at Bn te(&at
p(o'esn7a dan pe(atu(an pe(undan!:undan!an 3)D,-*
" Ada 4u&t pela&sanaan pem4e(an o4at dla&sana&an

sesua den!an pem4atasan 7an! dtetap&an, msaln7a o4at
&emote(ap, o4at (adoa&t', atau o4at untu& peneltan3
)D,-*
PKPO >31 1 Ada (e!ulas 6e('&as se4elum pen7e(aan o4at &epada SK, Pedoman/panduan, SPO
pasen 7an! melput 4ut( 1 sampa den!an $ pada ma&sud
dan tuuan3 ) %*
2 Ada 4u&t pela&sanaan 6e('&as se4elum o4at dse(a&an 4u&u 6e('&as < TTD 6e('&ato(
&epada pasen3 )D,- ,S*
" Ada 4u&t pela&sanaan dou4le e& untu& o4at 7an! TTD petu!as 7! 4e(4eda
a(us d8aspada )! ale(t*3 )D,O,-,S*
PKPO >32 1 Ada (e!ulas pen!o4atan ole pasen send(3 ) %* SPO
2 Ada 4u&t pela&sanaan pen!o4atan o4at ole pasen send( 'o(mul(
sesua den!an
(e!ulas3 )D,-*
" Adap(osesmonto(n!te(adappen!o4atanolepasensend( 'o(m PTO
3)D,-*
PKPO  1 Ada(e!ulaspemantauane'e&o4atdane'e&sampn!o4atse(ta SPO MESO

datatdalam status pasen3 )lat u!a AP 2 EP 1*3 ) %*
2 Ada4u&tpela&sanaanpemantauante(apo4at3)D,-* 5o(m PTO

" Ada 4u&t pemantauan e'e& sampn! o4at dan soslasas
pelapo(ann7a sesua den!an
pe(atu(an pe(undan!:undan!an3 )D,-*
PKPO 31 1 Ada(e!ulasmedatonsa'et77an!4e(tuuanmen!a(a&anpe Pedoman pela7anan Inst35a(mas
n!!unaano4at 7an! aman dan memnmalsas
&emun!&nan te(ad &esalaan pen!!unaan o4at sesua
den!an pe(atu(an pe(undan!:undan!an3 ) %*
2 Ada 4u&t pela&sanaan (uma sa&t men!umpul&an dan 'o(m KTD dan KD
memonto( selu(u an!&a &esalaan pen!!unaan o4at
te(masu& &eadan tda& da(ap&an, &eadan sentnel,
&eadan n7a(s ede(a, dan &eadan tda& ede(a3 )D,-*
" Ada 4u&t nstalas 'a(mas men!(m&an lapo(an &esalaan pelapo(an

pen!!unaan o4at )medaton e((o(* &epada tm
&eselamatan pasen (uma sa&t3 )D,-*
# Ada 4u&t tm &eselamatan pasen (uma sa&t mene(ma notulen (apat &oo(dnas
lapo(an &esalaan pen!!unaan o4at )medaton e((o(* dan
mena( a&a( masala atau n6est!as sede(ana, solus
dan tnda& lanutn7a, se(ta melapo(&an &epada Komte
Nasonal Keselamatan Pasen3 )lat u!a PMKP *3 )D,-*
$ Ada 4u&t pela&sanaan (uma sa&t mela&u&an upa7a notulen (apat &oo(dnas
mene!a dan menu(un&an &esalaan pen!!unaan o4at
)medaton e((o(*3 )lat u!a PMKP  EP 1*3)D,-*
STD NO ELEMEN PENILAIAN Y/T
Te)##( )e%'#+ (e$(#$ e!"#$ *!"%$*#+ ee*

#$ "e'% *!"%$*#+ e$#$ "#+#)#*#(, e$#$
MKE 1 1 #+e$ #$ *e'%#)#, +e)(# #$(#)+(# *'$+.  
Te)##( &%* e'#*+#$##$ *!"%$*#+ ee* #$(#)#

2 )%"#- +#*( #$ "#+#)#*#(. D,  L-#( %# TKS.3.2
Te)##( &%* e'#*+#$##$ *!"%$*#+ ee* e$#$

#+e$ #$ *e'%#)#. D, #-%'% ?PK 2.1 ?PK 2.2 AP
3 4.1 APK 1.2 PP 2.4
Te)##(&%*e'#*+#$##$*!"%$*#+ee*#$(#)+(#F'$+
4 .D,'-#(%# AP PAP SKP 2 TKS 1.2
Te)##( e"!)#; !%'#+ +e&## #+#) +()#(e

*!"%$*#+ e$#$ *!"%$(#+ #$ !%'#+ #$ '##$
MKE 1.1 1 )%"#- +#*(. D,.
De"!)#; +e*%)#$*%)#$$# ##( "e$#"&#)*#$

%+#, e($+, ##"#, +e)(# $*#( e$*#$ (e)"#+%* &%(#
-%)% #$ &#-#+# #$ e)%$#*#$ #$(#)# '#$
2 -#"&#(#$ #'#" &e)*!"%$*#+. D,
%"#- +#*( "e$e#*#$ $!)"#+ e$+ e'##$#$,

#*(% e'##$#$, +e)(# #*+e+ #$ )!+e+ %$(%*
%"#- +#*( "e$e#*#$ e$e)e"#- +e+%# e$#$
*e&%(%-#$ #$ &'#  )%"#- +#*( #* ## e(%#+
e$e)e"#- "#*# e)'%*#$ *e)# +#"# e$#$ -#*
3 (e)*#(. D,
%"#-+#*("e$e(#*#$$!)"#+#$-#)%++#"#*#$+
MKE 4 1 e=#)##*%)#(#$ (e#( #*(% *e +e'%)%- )%"#- +#*(.  
Te)##( &%* )!+e+ e$#"##$ $!)"#+ #$ #*%)#(

#$ (e#( #*(%  +e'%)%- )%"#- +#*( (e)"#+%* #$
%)e$( #$(#)# '#$ =!e &'%e #$ =!e )e. D,,S '-#(
2 %# PAP 3.2
MKE 5 1 Te)##( )e%'#+ (e$(#$ (#(# =#)# &e)*!"%$*#+.  
I$!)"#+ *!$+ #+e$ #$(#)+(# *'$+ (e)"#+%* PPA

&e)#+#) #(#+ )!+e+
#$ +e#$ &e)#'#$ #(#% ## +##( e$$ (e)(e$(%
#'#" )!+e+ #+%-#$
2 (%'+ #'#" )e*#" "e+. D,O
Se# #+e$ +e(e'#- )##( $# &%#( )$*#+#$ %'#$.

D, '-#( %#
3 MIM 15
D'#*%*#$ #+e+"e$ *e"#"%#$ #$ *e"#%#$ &e'##)
#+e$ +e)(# *e'%#)# #$ "e'% # +#"# e$#$ e
MKE 8 1 "#*+% #$ (%%#$ #$ =#(#(  )e*#" "e+. D,O
D'#*%*#$ #+e+"e$ *e&%(%-#$ e%*#+ %$(%* #+e$ #$
2 =#(#(  )e*#" "e+. D,O.
?#+' #+e+"e$ %$#*#$ %$(%* "e"&%#( e)e$=#$##$
3 *e&%(%-#$ e%*#+. D,O
Te)##(&%*(e)-###+e$e'#+*#$"e$e$#-#+'#+e+
"e$,#$!++, #$ )e$=#$# #+%-#$ #$ #*#$ &e)*#$.
MKE 9 1 D, '-#( %# ?PK 2.1
Te)##( &%* (e)-## #+e$ e'#+*#$ -#+' #+%-#$

#$ e$!&#(#$ (e)"#+%* -#+' #+%-#$ #$ e$!&#(#$
#$ #* -#)#*#$. D, '-#( %# PAP 2.4 #$ ?PK
2 2.1
3 Te)##(&%*e%*#+#+%-#$'#$%(#$)%"#-.D,
B'# '#*%*#$ $#*#$ "e* #$ "e"e)'%*#$

e)+e(%%#$ $#*#$
*e!*(e)#$ $!)"e =!$+e$(, #+e$ #$ *e'%#)#
&e'##) (e$(#$ )+*! #$
*!"'*#+ #$ ##( (e)# %$(%* ##( "e"&e)*#$
Pe"&e)#$ e%*#+ *e## #+e$ #$ *e'%#)# (e)*#(
e$#$ #+%-#$ #$
5 &e)*#$ "e'% (e*$* )e-#&'(#+. D,
Pe"&e)#$ e%*#+ *e## #+e$ #$ *e'%#)# (e)*#(

e$#$ #+%-#$ #$
&e)*#$ "e'% =#)# =%= (#$#$ #$ #"#$. D,,S
'-#( %# SKP 5 #$
6 PPI 9 EP 6
P)!e+!$#' e"&e) #+%-#$ PPA -#)%+ "e$e#*#$
MKE 11 1 #*(% #$ #e*%#( #'#" "e"&e)*#$ e%*#+. 
B'# e)'%*#$, e"&e)#$ e%*#+ *e## #+e$ #$

*e'%#)# &e)*#$ +e=#)# *!'#&!)# !'e- PPA (e)*#(.
2 D,
P## )!+e+ e"&e)#$ e%*#+, +(# -#)%+ "e$!)!$

#+e$ #$ *e'%#)# %$(%* &e)(#$# #$ "e"&e)
3 e$##( ##) ##( +e&## e+e)(# #*. ,S
Te)##( &%* '#*%*#$ :e);*#+ %$(%* "e"#+*#$

#+e$ #$ *e'%#)#
4 ##( "e"#-#" "#(e) e%*#+ #$ &e)*#$. D,
5 I$!)"#+:e)&#'e)*%#(e$#$"#(e)(e)(%'+.D,
DOKUMEN EVALUASI
SK, Pe!"#$/P#$%#$, SPO
)!)#" e%*#+ '%#) e%$ eG e$%'%-#$
!)"%') e%*#+
)##( *!!)$#+, !e)#$ +- ## "e'#'% SBA
(#&e' #$ e(# e) e+#/e)e'##$#$/e)e$+

#$#*, '#$+#, &%"'
(e)(%#$ '" '#!)#$ e"!)#; &%'#$#$

SK e$%$%**#$ e$e)e"#-, '+( #'#" S
SK, Pe!"#$ #$ P#$%#$, SPO
!+(e) =!e e"e)e$=  +e# %$(

SPO
<PPT
<PPT 'e$*#
+#"# e$#$ PPK 2,=#(#(#$ !)"%') e%*#+
!)"%') e%*#+ (e)&#)% ) *)#"#(
!)"%') e%*#+ (e)&#)% ) *)#"#(
TTD  !)"%') e%*#+
TTD  !)"%') e%*#+

TTD  !)"%') e%*#+
!)"%') e%*#+
!)"%') e%*#+
'e#He( eG DM  J #)"#+
TTD #+e$ '" !)" e%*#+

A#e$e(##$!)#$+#+e$=e#-#$e$e$#'#$$
e*+&e)#$(%$## %*%)#$ +e)(# *!"'e*+(#+
)%"#- +#*( #$ +e+%# e$#$ e)#(%)#$
PPI 1 1 e)%$#$%$#$#$.  
A#&%**e#(#$e'#*+#$##$*!!)$#+*e(%#!)#$+
#+e$#$IP<N#$ +e+%# e$#$ %*%)#$ #$
2 *!"'e*+(#+ e'##$#$ )%"#- +#*(. D,
%"#- +#*( "e$e(#*#$ )e%'#+ #$ "e'% 1
PPI 1.1 1 #$ 2 ## "#*+% #$ (%%#$. 
A# &%* e'#!)#$ e'#*+#$##$ *e#(#$ PPI !'e-

*e(%# !)#$+#+ *e## "$#$ )%"#- +#*( +e#
2 3 &%'#$. D,.
%"#- +#*( "e$e(#*#$ e)##( PPI/IP<N

I$e=!$ P)e:e$!$ #$ <!$()!' N%)+e e$#$
PPI 2 1 %"'#- #$ *%#';*#+ +e+%# e$#$ )e%'#+.  
A#&%*e)##(PPI/IP<N"e'#*+#$#*#$e$##+#$
+e)(#+%e):++e"%# *e#(#$ e$=e#-#$ #$
2 e$e$#'#$ $e*+. D, 
A# &%* (e)'#*+#$# e'#!)#$ e)##( PPI/IP<N
3 *e## *e(%# !)#$+#+ PPI. D,
A# )!)#" PPI #$ *e+e-#(#$ *e)# #$
*!")e-e$+
*!")e-e$+  +e'%)%- )%"#- +#*( %$(%*
"e$%)%$*#$ )+*! $e*+ (e)*#( e$#$ e'##$#$
*e+e-#(#$ ## #+e$ #$ "e$#=% #$ +e+%#
e$#$ '"% e$e(#-%#$ (e)*$, e!"#$ )#**
(e)*$, +(#$#) *e+e-#(#$ '$*%$#$ (e)*$, #$
PP I 5 1 e)#(%)#$ e)%$#$ %$#$#$. 
A# &%* e'#*+#$##$ )!)#" PPI %$(%*

"e$%)%$*#$ )+*! (e)(%'#) $e*+ ## #+e$.
2 D,O,,S
A# &%* e'#*+#$##$ )!)#" PPI %$(%*

"e$%)%$*#$ )+*! (e)(%'#) $e*+ ## +(# *'$+
#$ $!$*'$+ *e+e-#(#$ *e)#. '-#( %# KKS 8.4.
3 D,O,S
A# &%* e'#*+#$##$ )!)#" PPI #$ "e'%

&%) 1 +#"# e$#$ 7
4 ## "#*+% #$ (%%#$. D, 
%"#- +#*( "e$e(#*#$ )e%'#+ (e$(#$

e'#*+#$##$ +%):e'#$+ "e'% &%) 1 +#"#
PP I 6 1 e$#$ 7 ## "#*+% #$ (%%#$.  
A# &%* )%"#- +#*( "e$%+%$ +()#(e %$(%*
2 "e$%)%$*#$ )+*! $e*+ (e)+e&%(. D,
%"#- +#*( "e$e(#*#$ )+*!

)+*! $e*+ ##
)!+e%) #$ )!+e+ #+%-#$ $:#+ #$ &e)+*!
$e*+ +e)(# +()#(e %$(%* "e$%)%$*#$ )+*! $e*+.
PP I 7 1  
A# &%* e$;*#+ )!+e%) #$ )!+e+ #+%-#$

$:#+ +e)(# +()#(e %$(%* "e$%)%$*#$ )+*! $e*+.
2 D,
%"#- +#*( "e'#*+#$#*#$ +()#(e %$(%*

"e$%)%$*#$ )+*! $e*+ ## )!+e%) #$ )!+e+
3 #+%-#$ $:#+ #$ &e)+*! $e*+. D,O,,S
)+ (e'#- "e$##*#$ *e#(#$ e'#-#$ %$(%*

%"#- +#*( (e'#- "e'#*+#$#*#$ *e#(#$
*e#(#$ e'#-#$
%$(%* "e$%)%$*#$ )+*! $e*+  #'#" )!+e+
4 )!+e+ *e#(#$ (e)+e&%(. D,
%"#- +#*( "e$e(#*#$ )+*!

)+*! $e*+ ## )!+e+
*e#(#$
*e#(#$ e$%$#$ e'##$#$
e'##$#$ "e* #$
$!$"e* #$ &e)+*! (e)# $e*+ +e)(# +()#(e
e$=e#-#$$#
e$=e#-#$$# "e'% &%) 1 +#"# e$#$ 4
%"#- +#*( "e$#"$ )!+e+ +(e)'+#+ #$
+$e*+  '%#) %+#( +(e)'+#+ +e)##". D,O,
4
PPI 7.2.1 e'#*+#$##$ +(e)'+#+ '%#) )+
A# )e%'#+ (e$(#$ e$e(##$ &#(#+ *##'%#)+#

&#-#$ "e+ -#&+ #*# #$ %$#*#$ *e"&#'
)e%+e "e'% &%) 1 +#"# e$#$ 7 ##
PPI 7.2.2 1 "#*+% #$ (%%#$.  
A# &%* "!$(!)$, e:#'%#+, #$ $#* '#$%(

e'#*+#$##$ e$%$##$ *e"&#' )e%+e &#-#$
"e+ -#&+ #*# +e+%# &%) 1 +#"# e$#$ 7
2 ## "#*+% #$ (%%#$. D,O,
A#%$(*e)#e$e'!'#'$e$/'!$)#$"e$
A#%$(*e)#e$e'!'#'$e$/'!$)#$"e$e'e$#)
e'e$#)
#*#$e$#(#'#*+#$##$ +e+%# e$#$ e)#(%)#$
PPI 7.3 1 e)%$#$%$#$#$.
e)%$#$%$#$#$.  
B#$%$#$, #'%), #$ #+'(#+ '#%$) +e+%# e$#$
2 e)#(%)#$ e)%$#$ %$#$#$. O,
A# )e%'#+ e$e'!'##$ '$e$/'!$) +e+%# e$#$
PPI 7.3.1 1 e)#(%)#$ e)%$#$
e)%$#$  %$#$#$.  
Pe'#!)#$ ##$#$ '"&#- $e*+%+ +e+%# e$#$
)e%'#+ #$ '#*+#$#*#$
5 "!$(!)$, e:#'%#+, +e)(# $#* '#$%($#. D,O,
A# &%* e$#$#$#$ -#$'$ +e)(# e"&%#$#$

#)#- #$ *!"!$e$
#)#- +%#- *e'!'# +e+%# e$#$ e)#(%)#$
6 e)%$#$%$#$#$. O,
A# &%* e'#*+#$##$ +%e):+ #$ "!$(!)$

(e)-## *e#(#$ &%) 1
7 +#"# e$#$ 5 ## "#*+% #$ (%%#$. D,O,
B'# e$e'!'##$ '"&#- '#*+#$#*#$ !'e- -#* '%#)

)%"#- +#*( -#)%+
&e)#+#) #(#+ *e)#+#"# e$#$ -#* #$ "e"'*
$ #$ +e);*#+ "%(% +e+%# e$#$ e)#(%)#$
e)%$#$%$#$#$. '-#( MK 5.1 EP 4. D,O,
8
Pe"%'#+#)##$ e$##- #$ &e#- "##( +e+%#
PPI 7 4 1 1 e$#$ )e%'#+. D,O,
B'# e$e'!'##$ &e$# (##" #$ #)%"
'#*+#$#*#$ !'e- -#* '%#) )%"#- +#*( -#)%+
&e)#+#) #(#+ *e)#+#"# e$#$ -#* #$ "e"'*
$ #$ +e);*#+ "%(% +e+%# e$#$ e)#(%)#$
e)%$#$%$#$#$. D,O,
4
A# &%* #(# !*%"e$ '"&#- &e$# (##" #$
5 #)%". '-#( %#  PPI 7.2. D,
A# &%* e'#*+#$##$ +%e):+ #$ "!$(!)$ !'e-

IP<N (e)-## e$e'!'##$ &e$# (##" #$ #)%"
+e+%# e$#$ )$+ PPI, (e)"#+%* &'#
6 '#*+#$#*#$ !'e- -#* '%#) )%"#- +#*(. D,O,
A# &%* e'#*+#$##$ "!$(!)$ *e#(%-#$
7 )$+)$+ PPI. D,
%"#- +#*( "e$e(#*#$ )e%'#+ (e$(#$ e'##$#$

"#*#$#$  )%"#- +#*( #$ "e'% &%) 1 #$ 2
PPI 7.6 1 #$ ## ## "#*+% #$ (%%#$.  
A# &%* e'#*+#$##$ #$ e$"#$#$ &#-#$

"#*#$#$, e$!'#-#$, e"&##$/e"!)+#$, #$
#+'(#+ #$ (e)=#$(%" ## &%) 1 +#"# e$#$
5 +%#- '#*%*#$ e$e$#'#$ "e*#$+ #$ (e*$+
3 "e=-#$=#' #$ e$$ee)$ =!$()!'. D, O, 
%"#- +#*( (e'#- "e'#*+#$#*#$ e$'##$ )+*!

e$e$#'#$ $e*+ $e=!$ =!$()!' )+*
#++e++"e$(/I<A ## +e"%# )e$!:#+, *!$()%*+
#$ e"!'+ +e+%# e$#$ )e%'#+. D,O,
4
%"#- +#*( "e$e(#*#$ )e%'#+ e$e"#(#$

#+e$ e$#$ e$#*( "e$%'#) #$ #+e$ #$
"e$#'#" "%$(#+ )e$#- ""%$!=!")!"+e.
PPI 8 1  
%"#- +#*( "e$e#*#$ )%#$#$ %$(%* #+e$

#$ "e$#'#" "%$(#+ )e$#-
""%$!=!")!"+e +e+%# e$#$ e)#(%)#$
2 e)%$#$ %$#$#$. O,
%"#- +#*( "e$e(#*#$ )e%'#+ e$e"#(#$ #$

)!+e+ ()#$+e) #+e$ #)&!)$e +e#+e+  #'#"
PPI 8.1 1 )%"#- +#*( #$ *e'%#) )%"#- +#*(.  
A# &%* e'#*+#$##$ "!$(!)$ )%#$ (e*#$#$
4 $e# #$ e$e"#(#$ #+e$ +e=#)# )%$. D,O,
A#&%*'#*%*#$e%*#+*e##+(#e$(#$e$e'!'
##$#+e$$e*+%+ *# (e)# '!$#*#$ #+e$ "#+%*
e$#$ e$#*( "e$%'#) #(#% )%"#- +#*( #*
"e"%$# *#"#) e$#$ (e*#$#$ $e# :e$'#+
5 #'#"#- #$ "e*#$*. D,
%"#-+#*("e"%$#e#)$)%%*#$e$#$)%"#-
6 +#*('#$%$(%*#+e$ #) &!)$e +e#+e. D,
%"#- +#*( "e$e(#*#$ )e%'#+ &'# (e)#

'e#*#$ #+e$ !%(&)e#* e$#*( $e*+ #) &!)$e.
PPI 8.3 1  
%"#- +#*( "e$e#*#$ )%#$ +!'#+ e$#$

(e*#$#$ $e# &'# (e)# 'e#*#$ #+e$
!%(&)e#* +e+%# e$#$ e)#(%)#$ e)%$#$#$.
2 O,
A# &%* '#*%*#$ e%*#+ *e## +(# (e$(#$

e$e'!'##$ #+e$ $e*+%+ *# (e)# 'e#*#$
3 #+e$ !%(&)e#* e$#*( $e*+ #) &!)$e. D,
A#&%*e'#*+#$##$e'#-#$e$%$##$#'#(e'$
%$)*e##+e"%#
4 e## (e)"#+%* (e$## *!$()#*. D,
A# )e%'#+ ++(e" "#$#e"e$ #(# (e)$(e)#+

#$(#)# #(# +%):e'#$+ #$ #(# $*#(!) "%(%. '-#(
PPI 10 1 PMKP 2.1 EP 1.  
A# &%* e)(e"%#$ &e)*#'# #$(#)# K!"(e PMKP

Pe$$*#(#$ M%(% #$ Ke+e'#"#(#$ P#+e$ +e)(#
O)#$+#+ PPI %$(%* "e"&#-#+ -#+' +%):e'#$+ #$
2 "e)#$=#$ %'#$ %$(%* e)&#*#$. D,
A# &%* #(# *%"%'*#$ #$ #$#'++ %$(%*

"e$%*%$ *e#(#$ PPI (e)"#+%* #(# $e*+
&e)#+#) #(#+ ee"!'!* e$$ "!$(!) #$
3 !*%"e$(#+*#$. '-#( PPI 6 EP 2 #$ EP 3. D,
A# &%* e$#"##$ -#+' #$#'++ #(# #$

)e*!"e$#+ *e## K!"(e PMKP +e# # &%'#$.
'-#( PPI 6 EP 2 #$ EP 3. D,
4
DOKUMEN EVALUASI
SK " PPI, e!"#$ !)$+#+
)##( *!!)$#+
Pe!"#$ e'##$#$/ !e)#+!$#' PPI
'#!)#$ e:#'%#+ 3 &'$
SK e$%$%*#$ IP<N
TTD  '#!)#$ PPI
TTD IP<D ) '#!)#$ IP<N

SK, Pe!"#$ )!)#" *e)# PPI
'#!)#$ e:#'%#+
'#!)#$ e:#'%#+ #$ +!+#'+#+ -#$

-ee$e
SPO
)e$+()# e$%)%$#$ $e*+
SPO
I<A
'#!)#$ e:#'%#+ I<A
*'#(/+!+#'+#+
'#!)#$ "!$(!)$ #$ e:#'%#+
TDD
SPO
'#!)#$ "!$(!$ #$ e:#'%#+
e!"#$ %$( '$e$ #$ '#%$)
!&+e):#+ #$ ##$=#)#
SPO
!&+e):#+ #$ ##$=#)#
'#!)#$ "!$(!)$ #$ e:#'%#+ IP<N
MOU
!)" e$#(#'#*+#$##$ (e)-##
e$##-
MOU #$ +e);*#( -#* '%#)
'#!)#$ #(# !*%"e$(#+
'#!)#$ "!$(!)$ #$ e:#'%#+ IP<N
'#!)#$ "!$(!$ #$ e:#'%#+
Pe!"#$ e$e'e$#)##$ "#*#$#$,

SPO
'#!)#$ e:#'%#+
'#!)#$ I<A
e!"#$/#$%#$ e)##(#$ #+e$

e$#*( "e$%'#)
)%#$ +!'#+
SPO
+!+#'+#+
MOU
SPO
!&+e):#+ #$ ##$=#)#
+!+#'+#+
+!+#'+#+
e!"#$ e$$*#(#$ "%(% e'##$#$

)+
'#!)#$ )##( *!!)$#+ &e)*#'#
'#!)#$ e$%"%'#$ #(# #$ #$#'++

#(#
'#!)#$ #(# #$#'++

TKS 1 1 Pe"'*"e$e(#*#$)e%'#+#$"e$#(%)#+#"#e$ 
#$#$##  #'#" "#*+% #$ (%%#$ #$ ##(
&e)&e$(%* =!)!)#(e &'#+, e)#(%)#$ $(e)$#', #(#%
!*%"e$ '#$$# #$ +e)%#.  
2 A# e$e(##$ +()%*(%) !)#$+#+ e"'* (e)"#+%* 

)e)e+e$(#+ e"'* +e+%# e$#$ &e$(%* &##$
-%*%" *ee"'*#$ )%"#- +#*( #$ +e+%# e$#$
e)#(%)#$ e)%$#$%$#$#$. N#"# #&#(#$ 
#'#" +()%*%) !)#$+#+ (e)+e&%( -#)%+ +e=#)# e'#+
+e&%(*#$.  
3 A# e$e(##$ +()%*(%) !)#$+#+ )%"#- +#*( +e+%# 

e$#$ e)#(%)#$ e)%$#$%$#$#$.  
4 A#e$e(##$D)e*(%)%"#-S#*(+e+%#e$#$e)#(% 
)#$e)%$#$ %$#$#$.  
TKS 1.2 1 A# &%* e)+e(%%#$, )e:e &e)*#'#, #$ 
%&'*#+/+!+#'+#+ *e "#+#)#*#( (e$(#$ "+ )%"#-
+#*( +e+%# e$#$ )e%'#+. D,
2 A# e)+e(%%#$ )e$=#$# +()#(e+, )e$=#$# *e)#, #$ 

#$#)#$ )%"#- +#*( +e-#)-#) +e+%# e$#$
2 K%#';*#+ D)e*(%) %"#- S#*( +%#- +e+%# e$#$ 
e)+#)#(#$ #$ e)#(%)#$ e)%$#$%$#$#$. D,
3 D)e*(%)/D)e*+ %"#- S#*( #(%- (e)-## e)#(%)#$ 

e)%$#$ %$#$#$. D,
4 D)e*(%) %"#- S#*( (e'#- "e$#(%) !e)#+!$#' 

)%"#- +#*( +e#
-#) (e)"#+%* +e"%# (#$%$ ##& #$ e'#+*#$
#'#" %)##$ (%#+. D,
5 D)e*(%)/D)e*+ %"#- S#*( (e'#- "e$%+%$ #$ 

"e$%+%'*#$ )e$=#$# +()#(e+ +e)(# #$#)#$ &##
*e## e"'* #(#% )e)e+e$(#+ e"'* +e+%# e $#$
)e%'#+. '-#( %# TKS 1, TKS 1.1, #$ TKS 1.2.
D,
6 D)e*(%)/D)e*+ %"#- S#*( (e'#- "e"#+*#$ 

*e#(%-#$ +(# )%"#- +#*( (e)-## )e%'#+ )%"#-
+#*( #$ +%#- (e(#*#$. D,
7 D)e*(%)/D)e*+ %"#- S#*( "e$$#*'#$% +e"%# 

-#+' '#!)#$ e"e)*+##$ $(e)$#' #) e"e)$(#-
#(#% &##$ e*(e)$#' '#$$# #$ "e"%$#
*ee$#$#$ "e'#*%*#$ e"e)*+##$ )%"#- +#*(.
TKS 3.1 1 A# e$e(##$ e$+ e'##$#$ #$ &e)*#$ +e+%# 
e$#$ "+ )%"#- +#*(. '-#( %# AK 1, EP 1.  
2 A# e$e(##$ *%#';*#+ *e#'# %$( e'##$#$ 

(e)"#+%* *!!)$#(!) e'##$#$ &#* %$(%* %$(
e'##$#$ #$!+*, (e)#e%*, "#%%$ )e-#&'(#.
 
3 Ke#'# &#$/:+ %"#- S#*( &e)+#"# e$#$

*e#'# %$( e'##$#$ (e'#- "e$%+%$ =#*%#$ #$
e$+ e'##$#$ #$ +e#*#$  ## %$( +e+%#
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4 %"#- +#*( "e"&e)*#$

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"e$e)"# "#+%*#$ %$(%* e$$*#(#$ e'##$#$$#.
D,
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%# MKE 1.1, EP 4. D,
2 A# &%* )!+e+ e)e$=#$##$ #$ e'#*+#$##$
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)!e+ #$ &%(%-*#$. D,
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$*#(!)$#. '-#(
PMKP 2 #$ PMKP 2.1  
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"e$e"&#$*#$, +e)(# "e'#*+#$#*#$ )!)#"
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(%%#$. '-#( %# PMKP 5, EP 5. D,
3 I$!)"#+ (e$(#$ )!)#" e$$*#(#$ "%(% #$

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#'#" e$=###$ +#+#)#$ *e+e'#"#(#$ #+e$. D,
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PMKP 5  
2 #&%*e)#$D)e*(%)%"#-S#*(#$#)#Ke#'#B#$
/D:+#'#" )!+e+ e$%+%$#$ )!)#" e$$*#(#$
"%(%, )!)(#+, "!$(!)$ e'#*+#$##$, #$ )e$=#$#
e)&#*#$ "%(%. '-#( PMKP 4.2, 4.3, 4.4
D,
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+e"%# *!$()#* #$
+%#- '#*+#$#*#$. D,
4 Se# !*(e) #$ "e"&e)*#$ e'##$#$  )%"#-

+#*( +%#-
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)%"#- +#*(. D,
5 A# &%* Ke#'# &#$/ :+ e'##$#$ *'$+ #$

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#$ e"#$(#%#$ *!$()#* e'##$#$ *'$+ (e)"#+%*
*!$()#* e)#'#(#$ "e+ #$ (e'#- '#*+#$#*#$. '-#(
%# AP 5.1, EP 5, #$ AP
6.1, EP 5. D,
6 A# &%* Ke#'# &#$/:+ "#$#e"e$ #$ Ke#'#

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&e)#)+#+ #$ &e)(#$%$ ##& (e)-##
e$$#%#$, e"'-#$,
#$ e"#$(#%#$ *!$()#* "#$#e"e$. D,
7 A# &%* ##&'# *!$()#* $e!+#+*#$ %'#$ #(#%

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"e"&e)*#$ e'##$#$ #$!+*, *!$+%'(#+, #$
'##$#$ e)##(#$ #) '%#) )%"#- +#*(, +ee)
*e!*(e)#$ #)#* #%- (e'e"e=$e, )#!'! #)#*
#%- (e'e)#!'!, #$ $(e))e(#+ %$(%*
e"e)*+##$ #$!+* '#$ +ee) e'e*()!*#)!)#"
EK, e'e*()!e$+e#'!)#" EE, e'e*()!"!)#"
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'#*%*#$ )!+e+ *)ee$+#' #$ e"&e)#$
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e)#(%)#$ e)%$#$%$#$#$. D,
3 M%(% e'##$#$ #$ &e)*#$ !'e- !*(e) )#**

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D,
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"#*+% #$ (%%#$ +e)(# )e%'#+ e$%$##$
(e*$!'! "e* #$ !&#( &#)% #$ "#+- #'#" (#)#
% =!&# ()#' +e+%# e$#$ 1 +#"# e$#$ 3 #$
##  "#*+% #$ (%%#$ +e)(# "e"'* " e$#+#$
TKS 7.1 1 %"#- +#*( "e"%$# )e%'#+ (e$(#$ e$e'!'##$
e$###$ #'#( *e+e-#(#$, &#-#$ "e+ -#&+ #*#,
#$ !&#( #$ &e)+*! (e)"#+%* :#*+$ e$#$
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e)#(%)#$ e)%$#$%$#$#$. '-#( %# PKPO 2.
 
2 %"#- +#*( (e'#- "e'#*%*#$ e$;*#+ )+*! e$$

#) )#$(# +()&%+ #'#( *e+e-#(#$, &#-#$ "e+ -#&+
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D,
3 %"#- +#*( (e'#- "e'#*%*#$ e:#'%#+ (e$(#$

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"e$=e#- e$e'##$ #$ e"#'+%#$. D,
TKS 8 1 A# e$e(##$ +()%*(%) !)#$+#+ )%"#- +#*( +#"#

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2 A# e$e(##$ +()%*(%) !)#$+#+ *!"(e "e+ #$

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*e*%)#$#$ =#(#(#$ &'#  %$( e'##$#$ ##
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D,
4 Se# *e#'# %$( e'##$#$ (e'#- "e$%+%$ !'#

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#*#$ (%#+*#$  %$( e'##$#$ (e)+e&%( +e+%#
e$#$ e)#(%)#$ e)%$#$%$#$#$. '-#( %# KKS
2 EP 1 #$ EP 2. D,
5 Se#*e#'#%$(e'##$#$(e'#-"e$e'e$#)#*#$!)e
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##& +e)(# ee$#$ "e)e*#  %$( e'##$#$
(e"#( "e)e*# &e*e)#. '-#( %# KKS 7 EP 1, EP 2 #$
EP 3. D,
6 D#'#" !)e$(#+ (% &e)*#$ "#(e) (e$(#$

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8 A#*!!)$#+#$$(e)#+e'##$#$#'#"#%$(e'#
#$#$.D,
TKS 11 1 %"#- +#*( "e"%$# )e%'#+ (e$(#$ *)(e)#

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e$#$ 3 e$'##$  %$(.  
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##  "#*+% #$ (%%#$. '-#( %# PMKP 4.1 EP 1
#$ PAB 8.1. D,
3 Ke#'# %$( (e'#- "e'#*%*#$ e$%"%'#$ #(# #$

"e"&%#( '#!)#$ (e)$(e)#+ +e=#)# &e)*#'#. D,
TKS 11.1 1 Ke#'#%$(e'##$#$"e$e#*#$#(##$%$#*#$%

$(%*"e'#*%*#$ e:#'%#+ (e)-## )#** )!e+!$#'
&e)*e'#$%(#$ #) !*(e) #$ "e"&e)*#$ '##$#$ 
U$( (e)+e&%( +e+%# e$#$ )e%'#+ )%"#- +#*( '-#(
%# KKS 11 EP 2 #$ PMKP 4.1. D,
2 Ke#'#%$(e'##$#$"e$e#*#$#(##$%$#*#$%
4 A# &%* &#-# K!"(e Me* (e'#- "e'#*%*#$
"!$(!)$ #$ e:#'%#+ e$e)##$ #$%#$ )#**
*'$*, #'%), #$ #(#% )!(!*!' *'$+ +e-$# &e)-#+'
"e$e*#$ *e&e)##"#$ )!+e+ #$ -#+'. D,
TKS 12 1 D)e*(%) )%"#- +#*( "e$e(#*#$ )e%'#+ (e$(#$ (#(#

*e'!'# e* )%"#- +#*( #$ "e$#=% ## *!e e*
)%"#- +#*( $#+!$#', "e"&e$(%* *!"(e e* #$
"e$e'!'# e*# )%"#- +#*(, #$ "e$*!!)$#+*#$
+%&*!"(e
e* )!e+ #$ "e$e(#*#$ *!e e* e## )%"#-
+#*(. 
2 D)e*(%) )%"#- +#*( "e"#+*#$ #+%-#$ #+e$ #*

"e'#$#) $!)"#
$!)"# &+$+, $!)"# *e%#$#$, e*, #$ -%*%". D,
3 D)e*(%) )%"#- +#*( "e"#+*#$ )#*(e*

$!$+*)"$# #'#" -%&%$#$
*e)# #$ *e(e$(%#$ #(#+ #+%-#$ #+e$ e$#$
"e$$#( $!)"# -%*%"
3 e%'#+ %$(%* "#$#e"e$ e+ #$ "e$%*%$ -#'
-#' #$ *!$)!$(#+*#$ ## 'e"# e+ #'#"
e'##$#$ $!$*'$+ (e'#- '#*+#$#*#$. D,
4 Pe'#!)#$ &'# (e)# 'e"# e+ #'#" #+%-#$ #+e$

#$ #'#" e'##$#$ $!$*'$+ (e'#- '#*+#$#*#$.
D,
TKS 13 1 D)e*(%) %"#- S#*( "e$%*%$ (e)=(#$# &%##

*e(e)&%*##$ #$ '#$#'#+ #*%$(#&'(#+. 
2 D)e*(%) %"#- S#*( "e$e$;*#+,

"e$!*%"e$(#+*#$, #$ "e'#*+#$#*#$ e)&#*#$
e)'#*% #$ #* ##( (e)"#. D,O,
3 D)e*(%) )%"#- +#*( "e$e'e$#)#*#$ e$*#$

#$ "e$e#*#$ $!)"#+ +ee) &#-#$ %+(#*# #$
'#!)#$ #$ (e)*#( e$#$ &%## *e+e'#"#(#$
)%"#- +#*( &# +e"%# $:% #$ &e*e)# #'#"
)%"#- +#*(. D,O, 
4 D)e*(%) %"#- S#*( "e$e'#+*#$ &##"#$# "#+#'#-

(e)*#( &%## *e+e'#"#(#$ #'#" )%"#- +#*( ##(
e$;*#+ #$ *e$#'*#$. 
5 D)e*(%) %"#- S#*( "e$e#*#$ +%"&e) ## %$(%*

5 D)e*(%) %"#- S#*( (e'#- "e$%$#*#$
e$%*%)#$/$*#(!) "%(% %$(%* "e$e:#'%#+ #$
"e"#$(#% &%## *e+e'#"#(#$ #'#" )%"#- +#*(
+e)(# "e'#*+#$#*#$ e)&#*#$ #$ (e'#- (e)e$;*#+
#) e$%*%)#$ #$ e:#'%#+ (e)+e&%(. D, 
6 D)e*(%) %"#- S#*( "e$e)#*#$ +e&%#- )!+e+

%$(%* "e$=e#- *e)%#$/#"#* (e)-## $:%
#$ "e'#!)*#$ "#+#'#- (e)*#( e$#$ &%##
*e+e'#"#(#$ (e)+e&%(. D,O,
DOKUMEN EVALUASI
SK ?BL #$ D!*%"e$ ?BL. B%#( UAN
Pe"&%#(#$ ?BL, (#"&#-*#$ !+( ( !$( #
#'#" ?BL
SK SOTK PT K%)$# Se#-(e)#
SOTK S e:+ K!, S%+%$#$ )e%'#+,

e#&#( C
SK Pe$#$*#(#$ D)e*(%) I##-, ST, SIP
D!*%"e$ e:e Be)*#'# V+ #$ M+,

B%* P%&'*#+ V+ #$ M+ <#(%)e e&,
!(! V+ M+ K!)!), <!"#$ )!;'e
SK Pe)+e(%%#$ e$+()# #$ KA, D!*%"e$

e$+()#, D!*%"e$ KA, B%* Pe$%+%$#$
D!*%"e$ Kee###$ D)e*(%), ?BL !+( (
#+#' (e$(#$ )e*(%)
K%"%'#$ e%'#+ S, D#(# Pe)$#$
B%* ##( %$ M#$#e"e$ ##(

e$#$ B#$ #$ K!"(e, B%* ##(
D$#+, S%)#( D+!++
SK Pe)+e(%%#$ e$+()# #$ KA, D!*%"e$

e$+()#, D!*%"e$ KA, B%* Pe$%+%$#$
e$()# #$ KA UAN, P)!)#" *e)# %$(
!)" <e*'+ S%e):+ Ke#(%-#$ S(# eG

Ke#(%-#$ +e)##", Ke#(%-#$ -#$
-e$e
Le"&#) )e*!"e$#+ B##$ A%( E*+(e)$#',

B%* Pe"e)*+##$ A&+e$+, BAP, !(!,
B%* $#* '#$%(
SK Ke&#*#$ Pe'##$#$ S
SK U)##$ @#&#(#$ Ke#'# U$( Pe'##$#$ KKS

K#$( &##- &#$ Y#$"e, Kee#(#$
#$ @#$"e
B%* )##( )%$ K#& e$#$ K# U$( UAN
B%* ##( UMAN e$#$ Ke=#"#(#$,

Ke'%)#-#$, T/, Pe)+##, !*#,
P%+*e+"#+ K!!)$#+ e$#$ PKS #$
M#)*e$
Le#He(, <#(%)e Pe'##$#$  e&, !(!

Pe"#(e) #!,
B%* P)!+e+ e*)%("e$ KKS
B%* )##(, P)!)#" )e(e$+ #$ B%*

+!++ )e*(%)
B%* D*'#(
SK #$ Pe!"#$ PMKP, P)!)#" K!"(e K!"(e M%(%

M%(% 2018, SK Pe$e(##$ I$*#(!) M%(%
B%* ##( *!!)$#+ I$*#(!) M%(% K!"(e M%(%

'#!)#$ "%(% )e*(%) *e )e*(%) PT,
'#!)#$ 3 &%'#$#$
)##( '#!)#$ "%(% &%'#$#$/(#-%$#$
P)!)#" Pe$$*#(#$ M%(% )!)(#+ K!"(e M%(%
##( *!!)$#+ #$(#)# K#& #$ D)e*(%)

Be)*#+ *!$()#* P-#* *e3 #$ L+( K!$()#* Se*)e(#)#(
!)" *!$()#* !*(e) SDM
##( *#& (e)*#( e$#$ *!"(e "%(%

"e$e$# e"'-#$ #(#% e:#'%#+ *!$()#*
*'$+
##( *#& (e)*#( e$#$ *!"(e "%(%

"e$e$# e"'-#$ #(#% e:#'%#+ *!$()#*
"#$#e"e$
K'#%+%' $ (e)=#$(%" #'#" SK K!$()#*

TDD
TDD
TDD
SK #$ Pe!"#$ Pe'##$#$ #)"#+
(e)=#$(%" e$###$ #'*e+ ''
D##) Ie$;*#+ e+*!, B%* Le#'(#+ I$

D+()&%(!) #(#% PB !$( #
!)" e:#'%#+ )#$(# +()&%+ e)&e*#'#$

#)"#+ !'e- Ke#'# I$+(#'#+ #)"#+
B%* Le#'(#+ I$ D+()&%(!) #(#% PB
!$( #
SK SOTK %"#- S#*( #$ SOTK U$(

Pe'##$#$ #'#" Pe!"#$ Pe$!)#$+#+#$
SK Pe"&e$(%*#$ K!"(e Me+ SOTK

Pe!"#$ Pe'##$#$ %$( #$ P)!)#" Ke)# M#+$2 &#$
%$( 2018
P!'# Ke(e$###$ S, B%* e$%+%$#$ P!'# SDM

Ke(e$##$ #$ Pe!"#$ Pe$!)#$+#+#$
U$(, B%* )e*)%("e$ (e$## %$( e'##$#$
TO, D##) ?#), M#(e) !)e$(#+, E:#'%#+, SDM #$

L#!)#$ *e#(#$ !)e$(#+ "#+$2 *#&
TO, D##) ?#), M#(e) !)e$(#+ SPO

U$(, E:#'%#+, L#!)#$ *e#(#$ !)e$(#+
##( *!!)$#+ *#& #$ *#$(, )##(
*!!)$#+ *#$( #$ #$!(# e'#*+#$#, SPO
T)#$+e) #+e$, e"%'#$#$, e$##)#$
#+e$
SK Pe$e(##$ I$*#(!) M%(% e'##$#$ K!"(e M%(%
B%* %+%'#$ $*#(!) "%(% K!"(e M%(%
Pe$%"%'#$ #(# $*#(!) "%(% K!"(e M%(%
B%* $*#(!) "%(% &#$ e'##$#$ K!"(e M%(%

"e+, #$"e #$ *ee)##(#$ #$ B%*
e$'##$ *$e)# "e+
Pe$'##$ *$e)# e)##( B#$ Y#$"e,

B%* )##( C PPK K!"e/PMKP
Pe!"#$ "#$#e"e$ e* S, SK Pe$e(##$

K!"(e E*, SK Pe$e(##$ K!e E* P)!e+
#$ Pe##
SPO Pe$e=#+#$ Pe)$=#$, SPO Pe$#$#$#$

P#+e$ ##( D#)%)#(
P#$%#$ A+%-#$ P#+e$ #$ +e)##", B%* PAP

e"&e#$ #+%-#$ #+e$ #$ +e)##"
SK #$ P#$%#$ Pe'#!)#$ D'e"# E* N!$
K'$+
B%* e'#*+#$##$ "#$#e"e$ e* $!$*'$+
K!"(e M%(%
/PMKP
K!"(e M%(%
/PMKP
K!"(e M%(%
/PMKP
K!"(e M%(%
/PMKP
K!"(e M%(%
K!"(e M%(%
/PMKP
K!"(e M%(%
/PMKP
KKS 1 1 A# e$e(##$ e)e$=#$##$ *e&%(%-#$ +(# )%"#-
+#*( #$ &e)#+#) #(#+ e)e$=#$##$ +()#(e+ #$
e)e$=#$##$ (#-%$#$ +e+%# e$#$ *e&%(%-#$ )%"#-
+#*(.  
2 A#*ee'#+#$-%&%$#$#$(#)#e)e$=#$##$+()#(e+,e)
e$=#$##$(#-%$#$, #$ e)e$=#$##$ *e&%(%-#$ +(#.
D,
3 A# &%* e)e$=#$##$ *e&%(%-#$ +(# &e)#+#) #(#+

*e&%(%-#$ ## %$( *e)# *-%+%+$# %$( *e)#
e'##$#$. D,
KKS 2 1 A# *e&#*#$ #$ )!+e%) #$ (e(#*#$ )%"#-

+#*( (e$(#$ !'# *e(e$###$ #$ *e&%(%-#$ %"'#-
+(# +e+%# e$#$ #$ #*#$ #+#) %$(%*
"e$%+%$ e)e$=#$##$ +(#. P#$%#$ "e$#(%)
e$e"#(#$ #$ e$e"#(#$ *e"&#' +(#.  
2 A#e'#*+#$##$!'#*e(e$###$+e=#)#*!'#&!)#+e$#$
e)e$=#$##$+(# #$ "e'% %"'#-, e$+, #$
*%#';*#+. '-#( %# AP 6.2.D,
KKS 2.3 1 %"#- +#*( "e$e(#*#$ e$*#$, *e(e)#"'#$,
#$ e$e(#-%#$ +e)(# e$#$ e$e(##$ %)##$
(%#+, (#$%$ ##&, #$ ee$#$ +e+%# e$#$
e)#(%)#$ e)%$#$%$#$#$. '-#( %# TKS 3. 
2 Se# $#"# #&#(#$ ## e)+#)#(#$ e$*#$,

*e(e)#"'#$, #$ e$e(#-%#$. D,
3 Se#+(#)%"#-+#*("e"'*%)##$(%#+,(#$%$##
&,#$ee$#$ (e)"#+%* +(# *'$+ #$
"e'#*+#$#*#$ (%#+ "#$#e"e$ #$ #$ #*
$*#$ "e'#*%*#$ )#** "#$). D,
KKS 2.4 1 A#)e%'#+e$#(%)#$e$e"#(#$*e"&#'#)+#(%%$(

'##$#$*e'#$%$( '##$#$ *#)e$# #'#+#$ *!"e(e$+,
*e&%(%-#$ #+e$, #(#% *e*%)#$#$ +(# (e)"#+%*
"e"e)"&#$*#$ $'#$'#, *ee)=###$, #$ ##"#
+(#.  
2 A# !*%"e$ e)e$=#$##$ *e&%(%-#$ +(# )%"#- +#*(

&e)#+#) #(#+ e$#(%)#$ e$e"#(#$ *e"&#'. D,
3 A# !*%"e$ e$#(%)#$ e$e"#(#$ *e"&#'

&e)#+#) #(#+ e)"&#$#$ $'# *ee)=###$ #$
KKS 5 1 A#)e%'#+#$"e$e(#*#$)!+e++e'e*+%$(%*"e"#+
*#$e$e(#-%#$, *e(e)#"'#$, #$ *!"e(e$+ +(#
$!$*'$+ +e+%# e$#$ *e&%(%-#$ )%"#- +#*(.  
2 P)!+e+ +e'e*+ +(# $!$*'$+ '#*+#$#*#$ +e)##"

+e+%# e$#$ )e%'#+. D,
3 A$!(# +(# $!$*'$+ &#)% e:#'%#+ ## +##( "%'#
&e*e)# +e+%# e$#$ (#$%$ ##&$#. D,
4 U$(*e)#"e'#*+#$#*#$e:#'%#+*$e)#+(#$!$*'$+.
D,
5 E:#'%#++(#$!$*'$+'#*%*#$#$!*%"e$(#+*#$+e=
#)#&e)*#'#"$"#'
+#(% (#-%$ +e*#' +e+%# e$#$ )e%'#+. '-#( %# KKS
11. D,
KKS 6 1 'e *ee###$ "e"%#( *%#';*#+, e$*#$,

e'#-#$, #$ *!"e(e$+ +(#. D,
2 'e*ee###$"e"%#(%)##$(%#+#$!(#+(#.D,
3 ;'e*ee###$"e"%#()!+e+)e*)%("e$+(#.D,
4 'e*ee###$"e"%#()##(e*e)##$+(#.D 
4 %"#- +#*( "e$e#*#$ #*(%, #$#)#$, #$
#+'(#+ %$(%* +e"%# +(# #'#" &e)#)+#+
"e$*% e$*#$ #$ e'#-#$ #$ e)'%*#$.
D,
KKS 8.1 1 A#)e%'#+#$"e$e(#*#$e'#-#$(e*$*)e+%+(#+#

$(%$#)%$*#( #+#) ## +e'%)%- +(# #$ $*#(
'#$%( &# +(# #$ (e$(%*#$ !'e- )%"#- +#*(.  
2 S(##$"e$#"*!e&)%&e)'#-#$&#$(%#$-%
'#$%(.D,
3 A#&%*+(#e'#-'%'%+#)e'#-#$#$##("e"e)#
#*#$.D,,S
4 Pe'#-#$ %$(%* +e# +(# %'#$ +e+%# e$#$
)!)#" #(#% "$"#' %#
(#-%$ +e*#'. D,
KKS 8.2 1 # )e%'#+ *e+e-#(#$ #$ *e+e'#"#(#$ +(# +e)(#

e$#$#$#$ *e*e)#+#$  (e"#( *e)#.  
2 Be)#+#)#(#+ee"!'!e$#*$e*+"#*#)%"#-+#*
("e$e$;*#+ )+*! +(# (e)##) #(#% (e)(%'#) +e)(#
2 Se# !*(e) #$ "e"&e)*#$ e'##$#$  )%"#-
+#*( #& "e$#$#(#$#$ e)#$#$ +e+%# e$#$
)e%'#+ )%"#- +#*(. '-#( %# TKS 6 EP 4. D,
3 A# )!+e+ *)ee$+#' #$ e"&e)#$ *ee$#$#$

*'$+ !'e- )%"#- +#*( %$(%* e'##$#$ #$!+*,
*!$+%'(#+, #$ (#(# '#*+#$# #$ &e)*#$ !'e- !*(e)
)#** "#$) #) '%#) )%"#- +#*( +ee) *e!*(e)#$
#)#* #%- (e'e"e=$e, )#!'! #)#* #%-
(e'e)#!'!, #$ $(e))e(#+ %$(%* e"e)*+##$
#$!+* '#$ e'e*()!*#)!)#" EK,
e'e*()!e$+e#'!)#" EE, e'e*()!"!)#" EM,
+e)(# e"e)*+##$ '#$ #$ +e)%#. '-#( %# TKS 6.2
EP 2. D,
KKS 9.1 1 A#&%*'#*+#$#*#$:e);*#+#)+%"&e)%(#"#(e)-#

#*)ee$+#'(e)*#( e$*#$, $/+e);*#(, #$
*)ee$+#' '#$ +e+%# e$#$ e)#(%)#$ e)%$#$
%$#$#$ #(#% #$ *e'%#)*#$ !'e- $+(#$+
e$*#$ #(#% !)#$+#+ )!e+!$#' #$ #*%.
D,
2 A# &%* '#*+#$#*#$ *)ee$+#' (#"&#-#$ #)

2 A# &%* e"&e)#$ *ee$#$#$ *'$+ &e)#+#) #(#+
)e*!"e$#+ *ee$#$#$ *'$+ #) K!"(e Me*.
D,
3 A# &%* e'#*+#$##$ e"&e)#$ *ee$#$#$

(#"&#-#$ +e(e'#- "e'#*%*#$ :e);*#+ #) +%"&e)
#$ "e$e'%#)*#$ *)ee$+#'. D,
4 S%)#( e$%#+#$ *'$+ #$ )$=#$ *ee$#$#$ *'$+

#$!(# +(# "e+ #'#" &e$(%* (e)=e(#* #(#%
e'e*()!$* +!=! #(#% "e# '#$ (e)+e#  +e"%#
%$( e'##$#$ =!$(!-, *#"#) !e)#+, %$( #)%)#(,
$%)+e +(#!$ (e"#( #$!(# +(# "e+ (e)+e&%(
"e"&e)*#$ e'##$#$. D,
5 Se# #$!(# +(# "e+ -#$# "e"&e)*#$ e'##$#$

+e+;* #$ (e$(%*#$ !'e- )%"#- +#*(. D,
KKS 11 1 A# )e%'#+ e$'##$ *$e)# %$(%* e:#'%#+ "%(%

)#** )!e+!$#' &e)*e'#$%(#$, e*, #$ +'$ +(#
"e+. '-#( %# TKS 11 EP 2 #$ TKS 12 EP 1.  
2 A#&%*"!$(!)$#$e:#'%#+"%(%)#**)!e+!$#'
KKS 12 1 Be)#+#) #(#+ "!$(!)$ #$ e:#'%#+ &e)*e'#$%(#$
*)ee$+#' #$!(# +(# "e+ #$ '#*+#$#*#$ #'$
+e*( +e# 3 # (#-%$ (e(#*#$ *ee$#$#$
*'$+$# ##*#- (e(#, &e)(#"&#-, #(#% &e)*%)#$.  
2 A# &%* !*%"e$ +e# #$!(# +(# "e+ +e'#'%

e)&#-#)% +e=#)# e)!*. D,
3 A# &%* e"&e)#$ *ee$#$#$ (#"&#-#$
#+#)*#$ #(#+ *)ee$+#' #$ (e'#- :e);*#+ #)
+%"&e) #+'$# +e+%# e$#$ e)#(%)#$ e)%$#$
%$#$#$. D
KKS 13 1 A# )e%'#+ )%"#- +#*( e$#$ )!+e+ #$ ee*

%$(%* "e$%"%'*#$, :e);*#+ #$ "e$e:#'%#+
*)ee$+#' +(# *ee)##(#$ e$*#$, )e+()#+, $,
*ee$#$#$, e'#-#$, #$ e$#'#"#$.  
2 Te)+e# !*%"e$(#+ e$*#$, )e+()#+, +e);*#+,

$, e'#-#$, #$ e$#'#"#$. D,
3 Te)##(e'#*+#$##$:e);*#+#)+%"&e)#+'$##$+e)
##".D,
4 A# !*%"e$ *)ee$+#' #$ e'-#)# #) +e#
#$!(# +(# *ee)##(#$. D,
2 Te)+e# !*%"e$(#+ e$*#$, )e+()#+, +e);*#+,
$, e'#-#$, #$ e$#'#"#$. D,
3 Te)##(e'#*+#$##$:e);*#+#)+%"&e)#+'$##$+e)
##".D,
4 A# !*%"e$ *)ee$+#' #$ e'-#)# #) +e#
#$!(# )!e+!$#' e"&e) #+%-#$ PPA '#$$# #$
+(# *'$+ '#$$#. D,
KKS 17 1 A# e$e(##$ )$=#$ *ee$#$#$ *'$+ )!e+!$#'

e"&e) #+%-#$ PPA '#$$# #$ +(# *'$+ '#$$#
&e)#+#) #(#+ e$*#$, )e+()#+, +e);*#+, $,
e'#-#$, #$ e$#'#"#$ #$!(# +(# *'$+ '#$$#.
 
2 A#e'#*+#$##$)!+e+e"&%#(#$)$=#$*ee$#$#$*'
$++e+%#e$#$ e)#(%)#$ e)%$#$%$#$#$. D,
3 A# &e)*#+ *)ee$+#' #$ e'-#)# #) +e#

)!e+!$#' e"&e) #+%-#$ PPA '#$$# #$ +(# *'$+
'#$$#. D,
KKS 18 1
A#!*%"e$(#+e$'##$"%(%)!e+!$#'e"&e)#+%-
#$PPA'#$$##$ +(# *'$+ '#$$# &e)#+#+ 
#'#" )!)#" e$$*#(#$ "%(% )%"#- +#*(. D,
DOKUMEN EVALUASI
P!'# Ke(e$###$, KA #$ e$+()#
P!'# *e(e$###$ -#)%+ (e)=#$(%"

#'#" e$+()# #$ KA
B%* )##( !'# *e(e$###$, &%*

%+%'#$ %$( *e)#
SK P!'# Ke(e$###$ #$ P#$%#$

Pe$e"#(#$ #$ Pe$e"#(#$ Ke"&#'
S(#
B%* )##( !'# *e(e$###$, &%*

%+%'#$ %$( *e)#
SK Pe)+#)#(#$ @#&#(#$, UT
SK Pe)+#)#(#$ @#&#(#$, UT
'e Kee###$
SK
!)" e)"$(##$ +(# # %$(

SK
!)" )e=)%("e$
!)" e:#'%#+
'#!)#$ e:#'%#+
-#+' )##( e:#'%#+
;'e/&e)*#+
)!*e) *'#(
SK
*'#( B? '#$%( %(* T"
+e);*#(
+e);*#( %'#$
SPO
'#!)#$ :#*+$#+, '#!)#$ M<U

(#-%$#$
+%)#( :e);*#+
SPO
;'e *ee###$ +e+%# %)%(#$ !$(
+%)#( :e);*#+
!*%"e$ *)ee$+#' e)##(

e)##(
;'e *ee###$ +e+%# %)%(#$ !$(
+%)#( :e);*#+
!*%"e$ *)ee$+#' $#*e+ '#$
SK
KK PPA $#*e+ '#$
!*%"e$ *)ee$+#' $#*e+ '#$
!)"%') e$'##$
MIM 1 1 Te)##(%$(*e)##$"e$e'!'#SIMS.
S%"&e)##"#$%+##'#"%$(*e)#SIMS#$"e"'**!"
e(e$+#$
2 +%#- (e)'#-. D,
Te)##()e%'#+(e$(#$e$e'!'##$#(##$$!)"#+.
MIM 1.1 1
D#(# +e)(# $!)"#+ *'$* #$ "#$#e)#' $(e)#+*#$

+e+%# e$#$
*e&%(%-#$ %$(%* "e$%*%$ e$#"&'#$ *e%(%+#$.
2 D,
P)!+e+ e)e$=#$##$ *e&%(%-#$ $!)"#+ "e'&#(*#$ #

MIM 2 1 +#"# e$#$ = +e+%# e$#$ "#*+% #$ (%%#$. D,
P)!+e+ e)e$=#$##$ *e&%(%-#$ $!)"#+ "e$#=% ##
2 e)#(%)#$ e)%$#$%$#$#$. D,
Pe)e$=#$##$+e+%#*#$e$#$&e+#)#$*!"'e*+(#+)%"#
3 -+#*(.D,
D#'#" "e"&#$%$ ++(e" $!)"#+ )%"#- +#*(
MIM 3 1 "e'&#(*#$ )!e+!$#' e"&e) #+%-#$ PPA. D,
D#(##$$!)"#++#"#*#$+e+%#*e&%(%-#$e$%$#.
MIM 6 1 D,
Pe$%$# "e$e)"# #(# #$ $!)"#+ #'#" !)"#( #$

+e+%# e$#$
2 #$ &%(%-*#$. D,
3 Pe$%$#"e$e)"##(##$$!)"#+(e#(#*(%.D,
S(#e$!'#-#(#"e"'*-#*#*+e+*e#(##$$!)"#+#$
&%(%-*#$
4 +e+%# e$#$ (#$%$ ##&$#. ,S
%"#-+#*("e$e#*#$#+'(#+%$(%*"e$##(*#$$!)"#
+'"#-(e)*$ #$ $!)"#+ '#$ +e=#)# (e#( #*(% %$(%*
MIM 7 1 "e$%*%$ #+%-#$ #+e$. D,O,
%"#-+#*("e$e#*#$#+'(#+%$(%*"e$##(*#$I$!)"#
+'"#-(e)*$ #$ $!)"#+ '#$ +e=#)# (e#( #*(% %$(%*
2 "e$%*%$ e$*#$ *'$*. D,O,
%"#-+#*("e$e#*#$#+'(#+%$(%*"e$##(*#$$!)"#
+'"#-(e)*$ #$ $!)"#+ '#$ +e=#)# (e#( #*(% %$(%*
3 "e$%*%$ e$e'#$. D,O,
%"#- +#*( "e$e#*#$ #+'(#+ $(e)$e( %$(%*

"e$##(*#$ $!)"#+ '"#- (e)*$ #$ $!)"#+ '#$
4 +e=#)# (e#( #*(% %$(%* "e$%*%$ "#$#e"e$ D,O,
Te)##( &%* &#-# !)" )e*#" "e+ e:#'%#+ #$
e)&#-#)% (e)*$ +e+%# e$#$ *e&%(%-#$ #$ +e=#)#
3 e)!*. D,O,
e*#" "e+ #+e$ (e)+ e$#$ 'e$*# #$ e$#$

(%'+#$ #$ ##( &#=#. D,O
4
Te)##( )e%'#+ (e$(#$ #$*# #*(% e$"#$#$

&e)*#+ )e*#" "e+ #+e$, +e)(# #(# #$ $!)"#+
MIM 10 1 '#$$# (e)*#( e$#$ #+e$.  
D#'#" )e$(#$ #*(% e$"#$#$ &e)*#+ )e*#" "e+,

)%"#- +#*( "e$#"$ *e#"#$#$ #$ *e)#-#+##$ )e*#"
2 "e+. O,
D!*%"e$,+e)(##(##$$!)"#+#'#"&e$(%*&e)*#+"%+$
#-*#$+e(e'#- "e'#"#% e)!e #*(% e$"#$#$
+e+%# e$#$ e)#(%)#$ e)%$#$ %$#$#$. D,
3
Te)##()e%'#+#$(e(#*#$%$(%*"e$=e#-#*+e+e$
%$##$)e*#" "e+ &e$(%* *e)(#+ #$ #(#% e'e*()!$* (#$#
MIM 11 1 $.  
e*#" "e+ #'#" &e$(%* *e)(#+ #$ #(#% e'e*()!$*
2 '$%$ #) *e-'#$#$ #$ *e)%+#*#$. O,
A# &%* )e*#" "e+ #+e$ "e$%$#*#$ +#(% %$(
e$!"!)#$ )e*#" "e+ %$(%* +e# #+e$. D,,O
3
e*#" "e+ #+e$ (e)+e# %$(%* )##( #'#$, )## $#,
4 ##( #)%)#(, #$ e"e)*+##$ e$%$#$. D,O
5 Be)*#+)e*#""e+#+e$(e)+%+%$+e+%#)e%'#+.D,O
e*#" "e+ &e)+ $!)"#+ #$ "e"## %$(%*
MIM 13.1 1 "e$e$;*#+ #+e$. D,O
e*#" "e+ &e)+ $!)"#+ #$ "e"## %$(%*
2 "e$%*%$ #$!++. D,O
e*#""e+&e)+$!)"#+#$"e"##%$(%*"e"&e)%+
3 ;*#+#+%-#$ #$ e$!&#(#$. D,O
e*#" "e+ &e)+ $!)"#+ #$ "e"## %$(%*

"e$!*%"e$(#+*#$ e"&e)#$ #$ -#+' e$!&#(#$.
4 D,O
A*:(#+ "#$#e) e'##$#$ #+e$ MPP =#(#( #'#"
5 )e*#" "e+. D,O,
Te)##( )e%'#+ (e$(#$ M #+e$ ##( #)%)#( #$

"e"%#( #*(% *e#(#$#$ #$ *e'%#) #+e$, )$*#+#$
MIM *!$+ #+e$ +##( *e'%#) #) ##( #)%)#(, #$ $+()%*+
13.1.1 1 $#* '#$%( #+%-#$.  
2 e*#""e+#+e$)e:e+e=#)#&e)*#'#.D,
3 e:e"e$%$#*#$+#"e'#$"e#*'.D,
!*%+ )e:e ##'#- ## *e(e#(#$ #*(%, *e(e)&#=##$,
4 #$ *e'e$*##$ )e*#" "e+. D,
P)!+e+ )e:e (e)"#+%* + )e*#" "e+ -#)%+ +e+%#

e$#$ e)#(%)#$ #$
5 e)%$#$%$#$#$. D,
P)!+e+ )e:e (e)"#+%* )e*#" "e+ #+e$ #$ "#+-

)##( #$ #+e$
6 #$ +%#- %'#$. D,
?#+')e:e'#!)*#$+e=#)#&e)*#'#*e##)e*(%))%"#-+#
7 *(.D,
Te)##( )e%'#+ "e$e$# ):#+ #$ *e)#-#+##$

$!)"#+ (e)*#( #(# #+e$ #$ -#* #*+e+ (e)-## +
)e*#" "e+ &e)#+#) #(#+ e)#(%)#$ e)%$#$%$#$#$.
MIM 14 1  
2 Te)##(&%*)e%'#+'#*+#$#*#$.D,
3 Ke#(%-#$e'#*+#$##$)e%'#+"!$(!).D,
$*#+#$ %'#$ "e"%#( )##( *e+e-#(#$, e"e)*+##$

;++, #$ e"e)*+##$ #$!+*. D,
MIM 15 1
DOKUMEN EVALUASI
SPO, Pe!"#$ e)!)#$+#+#$
+e)F#(, <V
SPO, e!"#$ e'##$#$ M
&%* )##( IT
)##( *!!)$#+
SPO, "!$(!)$ =-e=*'+( #*+e+
M,'#!)#$ $#+,
#*+e+ $(e)$e( %(* e(%#+ *e+e-#(#$,

&%*% SIMS, %)$#' *e+e-#(#$
SPO e"&e)'#*%#$ M
M
SPO )e(e$+, SK e$e'e$#)##$ M
!&+e):#+ #$ ##$=#)#
SPO e"%+$#-#$,
SK, SPO
!&+e):#+ #$ ##$=#)#

M, <PPT
!$(2 '" &e)*#+ "
SOAP '" !)" M
!)" MPP
SK, SPO
)##( *!!)$#+
-#+' #%( #$ )##(
!$( )##(
)##( *!!)$#+ $ )e*(%)
SK, SPO
=-e=*'+( #*+e+
#%( #$ "!$(!)$
!)" +=-#)e '#$$$ J )e+%"e

%'#$
D)e*(%) )%"#- +#*( (e'#- "e"&e$(%* *!"(e/" PMKP

#(#% &e$(%* !)#$+#+
1 '#$$# %$(%* "e$e'!'# *e#(#$ +e+%# e$#$ e)#(%)#$
e)%$#$%$#$#$
(e)"#+%* %)##$ (%#+ #$ "e'% &%) 1 +#"# e$#$
10 #$
## ## "#*+% #$ (%%#$. 
PMKP 1 2 D)e*(%) )%"#- +#*( "e$e(#*#$ e$#$%$ ##& #(#

 ## %$( *e)#. 
I$:%  #'#" *!"(e/" PMKP #(#% &e$(%* !)#$+#+

3 '#$$# #$
e$#$%$ ##& #(# (e'#- '#- +e)(# *!"e(e$. D
K!"(e/" PMKP #(#% &e$(%* !)#$+#+ '#$$# (e'#-

4 "e'#*+#$#*#$
*e#(#$$#. D, 
%"#- +#*( "e"%$# e!"#$ e$$*#(#$ "%(% #$

1 *e+e'#"#(#$ #+e$ +e+%# e$#$ )ee)e$+ (e)*$. '-#(
%# TKS 4 EP 1. 
A# &%* e'#*+#$##$ )!)#" PMKP #$ "e'% #(#
3 &%) 1 +#"#
e$#$ 6 ## "#*+% #$ (%%#$. D,O,
%"#- +#*( "e"%$# )!)#" e'#-#$ PMKP #$

1 &e)*#$ !'e-
$#)#+%"&e) #$ *!"e(e$. 
P"$#$  )%"#- +#*( (e)"#+%* *!"(e "e+ #$

2 *!"(e *ee)##(#$ (e'#-
"e$*% e'#-#$ PMKP. D,
PMKP 3
Se"%# $:% #$ (e)'&#( #'#" e$%"%'#$, #$#'++,
#$ :#'#+ #(#
(e'#- "e$*% e'#-#$ PMKP, *-%+%+$# (e$(#$ ++(e"
3 "#$#e"e$ #(#. D,
S(#  +e"%# %$( *e)# (e)"#+%* +(# *'$+ '#- +e+%#

4 e$#$ e*e)##$
"e)e*# +e-#)-#). D,
K!"(e/" e$$*#(#$ "%(% #$ *e+e'#"#(#$ #+e$

1 #(#% &e$(%* !)#$+#+ '#$$# "e"#+'(#+ e"'-#$
)!)(#+ e$%*%)#$ e'##$#$ *'$+ #$ #*#$ e:#'%#+.
D,
K!"(e/" e$$*#(#$ "%(% #$ *e+e'#"#(#$ #+e$

Se# $*#(!) #$ (e(#*#$ 'e$*# e$#$ )!;'
5 $*#(!) #$
"e'% &%) 1 +#"# e$#$ 13 ## "#*+% #$
(%%#$. '-#( %# TKS
5. D
6 )e*(%) #$ *!"(e) PMKP "e'#*%*#$ +%e):+ (e)-##

)!+e+ e$%"%'#$ #(#. D,
%"#- +#*( "e$e(#*#$ e:#'%#+ e'##$#$ *e!*(e)#$

1 e$#$ #$%#$
)#** *'$+, #'%) *'$+, #(#% )!(!*!'. 
?#+' e:#'%#+ ##( "e$%$%**#$ e)&#*#$ :#)#+ #'#"

2 '"# !*%+ #)e#
PMKP 5.1
## e"&e)#$ e'##$#$. D,
%"#- +#*( (e'#- "e'#*+#$#*#$ #%( *'$+ #$ #(#% #%(

3 "e+ ##
#$%#$ )#** *'$+/#'%) *'$+ )!)(#+  $*#( )%"#-
+#*(. D,
%"#- +#*( "e"%$# )e%'#+ e$%*%)#$ "%(% #$

1 =#)# e"'-#$
$*#(!) "%(%  %$( *e)# #$ #$(#)# '#$ "e'% &%)
1 +#"# e$#$ 3
#$ ## ## "#*+% #$ (%%#$. 
K!"(e/" PMKP #(#% &e$(%* !)#$+#+ '#$$#
2 "e'#*%*#$ *!!)$#+
e$#$ %$( e'##$#$ #'#" e$%"%'#$ #(#. D,
%"#- +#*( (e'#- "e'#*%*#$ e$%"%'#$ #(# #$

$!)"#+ %$(%*
PMKP 7 3 "e$%*%$ #+%-#$ #+e$, "#$#e"e$ )%"#- +#*(,
e$*##$ )#**
)!e+!$#', +e)(# )!)#" "%(% #$ *e+e'#"#(#$ #+e$
+e=#)# "e$e'%)%-.
D,
K%"%'#$ #(# #$ $!)"#+ +#"#*#$ *e## &##$

4  '%#) )%"#- +#*(
+e+%# e$#$ e)#(%)#$ #$ e)%$#$#$%$#$#$.
D,
%"#- +#*( &e)*!$()&%+ (e)-## #(#&#+e e*(e)$#'

5 e$#$ "e$#"$
*e#"#$#$ #$ *e)#-#+##$. D,
%"#- +#*( "e"%$# )e%'#+ #$#'++ #(# #$

1 "e'% &%) 1 #$ 2
#$ ## ## "#*+% #$ (%%#$. 
%"#- +#*( (e'#- "e'#*%*#$ e$%"%'#$ #(#, #$#'++,

2
6 ?#+' #$#'++ #(# (e'#- +#"#*#$ *e## )e*(%), #)#
*e#'#
&#$/:+, #$ *e#'# %$( %$(%* $#*'#$%. D,
K!"(e/" PMKP #(#% &e$(%* !)#$+#+ '#$$# (e'#-

"e$%"%'*#$ #$
1 "e$#$#'++ #(# )!)#" PMKP )!)(#+ #$ "e'%
&%) 1 +#"#
e$#$ 4 #$ ## ## "#*+% #$ (%%#$. '-#( %#
PMKP 5. D,
A# &%* )e*(%) )%"#- +#*( (e'#- "e$$#*'#$% -#+'

PMKP 7.2 2 #$#'++ #(# #$
"e'% &%) 1 +#"# 4 #$ ## ## "#*+% #$
(%%#$. D,
A# &%* )!)#" PMKP )!)(#+ (e'#- "e$-#+'*#$

3 e)&#*#$  )%"#- +#*(
+e=#)# *e+e'%)%-#$. D,
A# &%* )!)#" PMKP )!)(#+ (e'#- "e$-#+'*#$

4 e;+e$+ e$%$##$
+%"&e) ##. D,
%"#- +#*( "e"%$# )e%'#+ :#'#+ #(# +e+%#

1
3 %"#- +#*( "e$$(e)#+*#$ e'#!)#$ *e##$ #$
e$%*%)#$ "%(% ##)
PMKP 9 +!'%+ +e)(# e)&#*#$ #$ '#*%*#$ (e)$(e)#+. D,
A# &%* )%"#- +#*( (e'#- "e'#!)#$ $+e$

4 *e+e'#"#(#$ #+e$ +e# 6
&%'#$ *e## )e)e+e$(#+ e"'* #$ &'# ## *e##$
+e$$e' (e'#-
'#!)*#$  +e# *e##$. '-#( %# TKS 4.1. D,
A# &%* )%"#- +#*( (e'#- "e'#!)*#$ $+e$

5 *e+e'#"#(#$ #+e$ *e##
K!"(e N#+!$#' Ke+e'#"#(#$ P#+e$ +e+%# e$#$
e)#(%)#$ e)%$#$%$#$#$. D,
P"$#$ )%"#- +#*( "e$e(#*#$ )e%'#+ e$+ *e##$

1 +e$$e' +e*%)#$*%)#$$#
+ee) %)#*#$ ## &%) 1 +#"# e$#$ 6 ##
M#*+% #$
T%%#$. '-#( %# PMKP 9 EP1. 
PMKP 9.1 %"#- +#*( (e'#- "e'#*%*#$ <A/AAM +e# ##

2 *e##$ +e$$e'  )%"#-
Se"%# e)&e##$ &e+#) +=)e#$= #$(#)# #$!++
5 )#!e)#+ #$
#$!++ #+=#!e)#+ +%#- #$#'++. '-#( %# PAB
7.2. D,
Ee* +#"$ #(#% !'# ee* +#"$ +e'#"# +e#+

6 "!e)#( #(#% "e$#'#"
#$ e"#*##$ #$e+(e+ +%#- #$#'++. '-#( %# PAB
3.2 #$ PAB 5. D,
Se"%# *e##$ '#$ #$ (e(#*#$ !'e- )%"#- +#*(

7 +e+%# e$#$ &%) 6
## "#*+% #$ (%%#$ +%#- #$#'++. D,
%"#- +#*( "e$e(#*#$ e;$+, e$+ #$ '#!)*#$,

1 #$ ++(e" e'#!)#$
PMKP 9.3
KN< #$ KT<. '-#( %# PMKP 9 EP1. 
2 A# #$#'++ #(# KN< #$ KT<. D,
1 A# )e%'#+ e$%*%)#$ &%## *e+e'#"#(#$. '-#( %#

TKS 13. 
PMKP 10
2 D)e*(%) )%"#- +#*( (e'#- "e'#*+#$#*#$ e$%*%)#$
&%## *e+e'#"#(#$. D,
%"#- +#*( (e'#- "e"&%#( )e$=#$# e)&#*#$ (e)-##

1 "%(% #$ *e+e'#"#(#$ &e)#+#) #(#+ -#+' =###$ "%(%.
D,
2 %"#- +#*( "e"%$# ##) )+*!  $*#( )%"#-
+#*( #$ +e*%)#$*%)#$$# "e'% )+*! #$ ## 
&%) 1 +#"# 6 #$ ## ## "#*+% #$ (%%#$. D,
%"#- +#*( (e'#- "e"&%#( +()#(e %$(%* "e$%)#$

3 )+*! #$ ##  &%)
PMKP 12
1 +#"# e$#$ 6. D,
A# &%* )%"#- +#*( (e'#- "e'#*%*#$ #'%)e "!e eRe=(

4 #$#'++ #$#'++
ee* "!%+ *e##'#$ +e(#-%$ +e*#' ## )!+e+ &e)+*!
$ #$
)!)(#+*#$. D,
%"#- +#*( (e'#- "e'#*+#$#*#$ $#* '#$%( -#+' #$#'++

5 "!%+ #"#*
*e##'#$. MEA. D,
DOKUMENTASI EVALUASI
SK, Pe!"#$ PMKP
SK
+e);*#+, +!+#'+#+
)!*e) PMKP, $!(%'e$ )##( *!))$#+
e!"#$ PMKP
'#!)#$ "%(%
Pe!"#$ PMKP
D*'#(/+e);*#(
D*'#(/+e);*#(
D*'#(/+e);*#(
D*'#(/+e);*#(
!)" )!;' $*#(!)
-#+' #%(
P#$%#$ PPK
-#+' #%( PPK
-#+' #%( PPK
SPO, P#$%#$ e$=#(#(#$ > e'#!)#$

)##( *!!)$#+ e) &%'#$
#(# e'#!)#$
#(# +(#++* "%(% (#"'*#$ '"

e&
#(#&#+e "%(% (#"'*#$  "#$

)+
Pe!"#$ PMKP, SPO
#(# +(#+* "%(%

$!(%'e$ )##( *!!)$#+
'#!)#$ $*#(!) *%$=
$!(%'e$ )##(
e)&#$$#$ #(# +(#+*
#(# +(#+* IAM
SPO, Pe!"#$ PMKP

-#+' #(# #$#'++
$!(%'e$+ )##( e"'* )+
&%* '#!)#$ IKP
SPO
e'#!)#$ <A
#(# #$#'++ !)" e'#!)#$ !e)#+
#(# #$#'++
#(# #$#'++
SPO, P#$%#$
e'#!)#$ #(#
SPO, P#$%#$ &%## *e+e'#"#(#$
)##( e:#'%#+
)e$+()# e)&#*#$
'+( ##) )e+*!
)e$+()#
'#!)#$ MEA
'#!)#$ e:#'%#+ MEA

STD NO ELEMEN PENILAIAN Y/T DOKUMENTASI EVALUASI
1 D)e*(%) )%"#- +#*( #$ "e)e*# #$ &e)(#$%$ +%)#( IMB, I$ !e)#+!$#'
##& (e)-##
(e)-##
"#$#e"e$ #+'(#+  )%"#- +#*( +e-#)%+$#
"e"%$# #$ "e"#-#"
e)#(%)#$ e)%$#$%$#$#$ #$ e)+#)#(#$
'#$$# #$ &e)'#*% %$(%*
&#$%$#$ #$ #+'(#+ )%"#- +#*(. D,
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+e(e"#(  '%#) )%"#- +#*(. D,
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+(#, #$ e$%$%$ +e=#)# (e)(%'+
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$ "e)%#*#$ +#(% )!)#"
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(e)+e&%( "#+- &e)'#*% #$ +%#- '#!)#$ )!*e) K3 S
MK 2 (e)#*#$ +ee$%-$#. D,
3 A# &%* e$$#%#$ #$ e"&#-#)%#$ )!)#" '#!)#$ e:#'%#+
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D,
4 A# &%* &#-# (e$#$(/e$e#
(e$#$(/e$e# '#-#$  #'#" MOU
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"e"#(%- +e"%# #+e* )!)#" "#$#e"e$ )+*!
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(e)e$;*#+ #'#"
&%) 1 +#"# 4 ## "#*+% #$ (%%#$. D,
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'$*%$#$ #$ ##( (e)# ##
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"e'% )+*! #$ ## &%) 1
+#"# e$#$ 6 ## "#*+% #$ (%%#$ #$
"e)%#*#$ +#(% )!)#" $%*
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%$(%* "e$e)#*#$ )!)#"
"#$#e"e$ "e'% &%) 1 #$ 2 ## "#*+% #$
(%%#$. 
2 P)!)#" (e)+e&%(
(e)+e&%( "#+- &e)'#*% #$ +%#- !$( '" SK T" K3 S
MK 3 (e)#*#$ +ee$%-$#. D,
3 A# &%* e$$#%#$ #$ e"&#-#)%#$ )!)#" +e);*#(
)!)#" (e)+e&%( &'# (e)#
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+e*%)#$*%)#$$# +e# (#-%$.
D,
4 A# &%* (e$#$(/e$e# '#-#$  #'#" '$*%$#$ '#!)#$ e:#'%#+ *e#(#$
)%"#- +#*( +%#-
"e"#(%- +e"%# #+e* )!)#" "#$#e"e$ )+*!
#+'(#+ #$ '$*%$#$ #$ (e)e$;*#+ #'#"
&%) 1 +#"# 4 ## "#*+% #$ (%%#$. D,
1 %"#- +#*( "e"%$# )e%'#+ (e)"#+%* )!)#"  e!"#$ K3 S, SK

e$e'!'##$ *e+e'#"#(#$
#$ *e#"#$#$ #$ "e'% &%) 1 +#"# e$#$
6 ## "#*+% #$ (%%#$.

2 A# %$( *e)# #$ &e)(#$%$ ##& (e)-## '#!)#$ )##( *!!)$#+ " K3 S
e$e'!'##$ *e+e'#"#(#$
#$ *e#"#$#$. D,
3 %"#- +#*( (e'#- "e'#*%*#$ e$;*#+ #)e##)e# '+( #)e# &e)e+*!
#$ &e)+*! "e"%$#
)+* )e+(e) ##) )+*! #$ &e)-%&%$#$ e$#$
*e+e'#"#(#$ #$
*e#"#$#$ #+'(#+. D,
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MK 4 e$%$%$ (e)"#+%*
(#"%, +(# )%"#- +#*(, e## *!$()#*, #$ +e"%#
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SKP"1.D,O,
5 %"#- +#*( (e'#- "e'#*%*#$ e"e)*+##$ #+'(#+ *#)(% e"e)*+##$ &e)*#'#
+e=#)# &e)*#'#, "e"&%#(
)e$=#$# e)&#*#$, #$ (e'#- "e'#*+#$#*#$
e)&#*#$. D,O,
6 %"#- +#*( (e'#- "e"#+#$ "!$(!)$ ## #)e#  e"#+#$#$ ==(:
#$ &e)+*!
*e+e'#"#(#$ #$ *e#"#$#$. O,
7 %"#- +#*( (e'#- "e$e#*#$ #+'(#+ #$ #"#$
+e+%# e$#$ e)#(%)#$
e)%$#$%$#$#$. O,
1 %"#- +#*( "e"%$# )e%'#+ #$ "e$#(%)  Pe!"#$ K3 S, SK
#+e+"e$ )+*! )#*!$+()%*+
P<A. '-#( %# PPI 7.5. 
2 %"#- +#*( "e'#*%*#$ #+e+"e$ )+*! )#*!$()%*+ !)"%') #++ )+*! P<A
P<A &'# ## )e$=#$#
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#$ (%%#$. D,
MK 4.1
3 %"#- +#*( "e$#"&' $#*#$ &e)#+#) #(#+ -#+' '#!)#$ e:#'%#+
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"e"$"#'*#$ )+*! +e'#"# e"&!$*#)#$,
*!$+()%*+, #$ )e$!:#+. D,O,
4 %"#- +#*( "e"#+*#$ &#-# *e#(%-#$ '#!)#$ e"&#$%$#$
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!*%"e$(#+*#$. '-#( %# MK 3. D,O,
1 %"#- +#*( "e$e#*#$ #$#)#$ %$(%*  )e$+()# )+

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AP 5 #$ AP 6. D,
2 %"#- +#*( "e$e#*#$ #$#)#$ %$(%*
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"e$#$ ++(e", &#$%$#$, #(#% *!"!$e$ #$
MK 4.2 e)'%*#$ ##) #+'(#+
(e(# ##( &e)!e)#+ +e=#)# #"#$ #$ ee*.
D,O,
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*!$()%*+, #$ e"&!$*#)#$. D,
4
1 %"#- +#*( "e"%$# )e%'#+ #$ "e$#(%) B3  SK, P#$%#$, SPO
+e)(# '"&#-$# +e+%#
e$#$ *#(#!) ?O #$ e)#(%)#$ e)%$#$
%$#$#$, "e'% &%) 1
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AP 5.3.1 AP 5.6 AP
6.3 AP 6.6 #$ PKPO 3. 
2 %"#- +#*( "e"%$# ##) B3 +e)(# '"&#-$# '+( B3 #$ '"&#- S
'e$*# #$ (e)&#)% +e+%#
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&e)#=%$ +e)(# '"&#-$#. '-#(
%# AP 5.5 #$ AP 6.6. D,O,
3 A# &%* &#-# %$(%* e$###$/e"&e'#$ B3 '#")*#$ !)" MSDS
MK 5 #$ e"#+!* +%'e) +%#- "e'#")*#$ MSDS.
D,O,
4 Pe(%#+ (e'#- "e$%$#*#$ APD #$ &e$#) ## !&+e):#+ #$ ##$=#)#
#*(% "e$#$#$
-#$'$ B3 +e)(# '"&#-$# #$  #)e# (e)(e$(%
%# +%#- ## ee #+-e).
'-#( %# AP 5.3.1. O,
5 B3 +e)(# '"&#-$# +%#- &e) '#&e'/)#"&%)#"&% e"&e)#$ '#&e'  B3
+e+%# e$#$ e)#(%)#$ #$ e)%$#$%$#$#$.
'-#( %# PKPO 3 EP 2. O,
6 A# '#!)#$ #$ #$#'++ (%"#-#$, e'#!)#$ $+e$

##)#$/##$#$ eG!+%)e, #$ $+e$
'#$$#. D,
7 A# &%* !*%"e$(#+ e)+#)#(#$ #$ "e'% +%)#( $ e$#(%)#$ '"&#-,
$, '+e$+, #(#% *e(e$(%#$
e)+#)#(#$ '#$$#. D,
1 %"#- +#*( "e"%$# )e%'#+ %$(%*  SK, P#$%#$ B3
e$"#$#$ #$ e$!'#-#$ '"&#-
B3 +e=#)# &e$#) #$ #"#$ +e+%# e$#$ *e(e$(%#$
e)#(%)#$ e)%$#$%$#$#$.
'-#( %# AP 6.2 EP 4 MK 1 EP 3. 
2 Pe$"#$#$ '"&#- B3 +%#- "e"%$# $ TPS $ '"&#-
B3 #$ "#+- &e)'#*% #$ +e+ %# e$#$
e)%$#$%$#$#$. D,O,
3 %"#- +#*( +%#- "e"%$# I$+(#'#+ Pe$!'#-#$ $ IPAL

A) L"&#- IPAL e$#$
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D,O,
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e:#'%#+. D,O,
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&'# (e)# *e##'#$ '+()* #(#% #) &e)+-
(e)*!$(#"$#+ #(#% (e)#$%.
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(e)# (#(# *e'!'# )+*!.
D,
6 %"#- +#*( "e"%$# +%"&e) '+()* #$ #) &e)+- MOU, e$+e(
#'(e)$# #'#" *e###$
e"e)e$+. D,,O
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*%)#$$# "e'% &%) 1 +#"#
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+e+%# e$#$ e)#(%)#$ +e*#'
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e"e)*+##$ "%(% #) #$
&e)"#+#'#- #$ !*%"e$(#+*#$. D,
1 %"#- +#*( "e"%$# )e%'#+ ++(e" e'#!)#$ SPO
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*e=e'#*##$ +e# )!)#" "#$#e"e$ )+*!
#+'(#+. 
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#$#'++. D,
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MK 10 "e$#$ #(#% "e$$*#(*#$
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#$ "e$%)%$*#$ )+*! 
'$*%$#$. D,,O
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e'#*+#$##$ )!)#"
"#$#e"e$ )+*! #+'(#+ (e'#- "e"&%#( '#!)#$
*e## )e*(%) )%"#- +#*(
+e# 3 &%'#$. '-#( %# MK 3. D,
1 %"#- +#*( "e"%$# )!)#" e'#-#$ SPO
"#$#e"e$ #+'(#+ #$
*e+e'#"#(#$. 
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*!"!$e$ #) )!)#"
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"e'#*+#$#*#$ (#$%$ ##&$# e$#$ ee*.
'-#( %# AP 5.3 AP 6.3.
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D,
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+e# )!)#" "#$##"e$ #+'(#+. Ke#(#$
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"e'#!)*#$ *e+e'#"#(#$,
*e#"#$#$, #$ )+*! '#$$#. ,S
3 S(# ##( "e$e'#+*#$ #$/#(#% "e"e)##*#$
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)!+e%) #$ #)+#+ #'#" e$"#$#$,
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#+ "e+ +e)(# '"&#- B3. ,S
4 S(# ##( "e$e'#+*#$ #$/#(#% "e"e)##*#$
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#'#" e$#$#$#$ *e#)%)#(#$ +e)(# &e$=#$#
$(e)$#' #(#% e*+(e)$#'
=!""%$(. ,S
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"e+ +e+%# e$#$ %)##$ &e)*#'#
(%#+ #$ '#*%*#$ (e+ +e=#)# &e)*#'#. D,,S
2 S(# &e) e'#-#$ %$(%* "e$#'#$*#$ ++(e"
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(%#+ #$ '#*%*#$ (e+ +e=#)# &e)*#'#. D,,S
MK 11.2
3 S(# &e) e'#-#$ %$(%* "e"e'-#)# e)#'#(#$
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(%#+ #$ '#*%*#$ (e+ +e=#)# &e)*#'#. D,,S
4 S(# &e) e'#-#$ %$(%* "e"e'-#)# ++(e"
%'(#+ +e+%# e$#$ %)##$
(%#+ #$ '#*%*#$ (e+ +e=#)# &e)*#'#. D,,S
A# )e%'#+ )%"#- +#*( (e$(#$ e'#*+#$##$ PONEK

1 24 #"  )%"#- +#*( SK, Pe!"#$, P#$%#$, SPO
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)%"#- +#*(.  
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2 #'#" "e$%+%$ *e#(#$ $!(%'e$ )##( *!!)$#+
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MD+ 1 e'##$#$ *e##(
#)%)#(#$ PONEK 24 @#". D,
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4 '-#( %# AK.5. S #) e"#+, SMS
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5 e:#'%#+ )!)#" )%"#- +#*( '#!)#$ e:#'%#+
+##$ &% #$ &# SSIB. D,
A# &%* e'#!)#$ #$ #$#'++ #$ "e'% 1

6 +#"# e$#$ 4  "#*+% #(# #$#'++
#$ (%%#$. D,
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*e)#$#.  ✓
2 A# &%* e'#-#$ e'##$#$ PONEK. D,  +e);*#(
MD+ 1.1
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4 Te)+e# )%#$ e'##$#$ #$ "e"e$%- %#$#$

e)+#)#(#$ %$(%* PONEK.D,O,
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2 e"&e)#$ ASI E*+'%+. !&+e):#+ #$ ##$=#)#
MD+ 1.2 O, 
A# &%* e'#*+#$##$ e%*#+ #$ e)##(#$

3 "e(!e *#$%)% PMK ## !+(e)/'e#He(
A#$# )e%'#+ )%"#- +#*( #$ %*%$#$ e$%-

1 "#$#e"e$ #'#" SK, P#$%#$, SPO
e'##$#$ e$#$%'#$#$ ?IV/AIDS.  
P"$#$ )%"#- +#*( &e)#)+#+ #'#"

2 "e$%+%$ )e$=#$# e'##$#$ $!(%'e$ )##( *!!)$#+
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P"$#$ )%"#- +#*( &e)#)+#+ #'#"

3 "e$e(#*#$ *e+e'%)%-#$
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e$#$%'#$#$ ?IV/AIDS (e)"#+%*
e'#!)#$$#. D,
MD+ 2
4 Te)&e$(%* #$ &e)%$+$# T" ?IV/AIDS )%"#- SK, )!*e)
+#*(  D,  
e)'#*+#$#$# e'#-#$ %$(%* "e$$*#(*#$

5 *e"#"%#$ (e*$+ T" +e);*#(
?IV/AIDS +e+%# +(#$#). D,
Te)'#*+#$#$# %$+ )%%*#$ ?IV/AIDS ## )%"#-

6 +#*( +e+%# e$#$ MOU
*e&#*#$ #$ &e)'#*%. D
Te)'#*+#$#$# e'##$#$ V<T, AT, PMT<T, IO, OD?A

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2 Ada 4u&t pela&sanaan &ont(ol mutu pela7anan lapo(an mutu

2 %enanaasuandnte!(as&andand&oo(dnas&andd 'o(m ass asuan te(nte!(as

2 Dselu(ua(ea(umasa&t4antuandupdasa(d4e(&an 8a8ana(a dan smulas

PA+ "3$ 1 Ada(e!ulassuanpasenpen7a&tmenula(danmmuno: SK, panduan, SPO

# Ada 4u&t pela&sanaan asuan te(adap populas 'o(m asuan &e&e(asan

# Ma&anan dsap&an dan dsmpan den!an o4se(6as dan 8a8ana(a, pa&n!an

# Pasen dan &elua(!a d4e(&an edu&as tentan! 'o(m edu&as

2 Pe'##$#$ #$e+(e+, +e)(# +e#+ "!e)#( #$

2 A# &%* e$#$%$ ##& e'##$#$ #$e+(e+ &e'%" (e)'#*+#$#

3 A# &%* "!$(!)$ #$ e:#'%#+ )!+e+

4 A# &%* "!$(!)$ #$ e:#'%#+ )!+e+

6 A#&%*e'#*+#$##$)!)#""%(%#$*e+e'#"#(# &'" '#*+#$#*#$, *!'#&!)#+ $ PMKP

PAB 3 1 A#)e%'#+)%"#-+#*(#$"e$e(#*#$e"&e)#$ SK, Pe!"#$/P#$%#$/SPO

2 A# &%* e'#*+#$##$ +e#+ +e+%# e$#$ !)"%') +e#+

2 P)!e+!$#' e"&e) #+%-#$ PPA #$ SK, Pe!"#$/P#$%#$/SPO

2 A# &% e$#$%$ ##& e'##$#$ #$e+(e+ &e'%" (e)'#+#$#

6 A#&%e'#+#$##$)!)#""%(%#$e+e'#"#(# &'" '#+#$##$, !'#&!)#+ $ PMKP

PAB 3 1 A#)e%'#+)%"#-+#(#$"e$e(##$e"&e)#$ SK, Pe!"#$/P#$%#$/SPO

2 A# &% e'#+#$##$ +e#+ +e+%# e$#$ !)"%') +e#+

PAB 3.2 1 D'#%#$#+e+"e$)#+e#+#$=#(#(#'#")e#" =)!++ =-e= %'#$

2 Se!)#$ #$ !"e(e$ "e'#%#$ e"#$(#%#$ =-e='+( "!$(!)$

3 K)(e)# e"%'-#$ %$##$ #$ =-e='+( 

PAB 4.1 1 A+e+"e$)#$%+'#%*#$%$(%+e##+e$+e& =-e='+( #$ SPO, "!$(!)$

2 #(%"#+%)%#$e"%'-#$#$$#-*#$#)) !)" #$e+(e+, 'e"&#)#$ "!$(!)$

3 ?#+'#+e+"e$#$%$##$%$(%"e$e$(%#$)e$ M SOAP, <PPT &e'%" '#%*#$

2 A#&%'#!)#$!e)#+"e"%#(#'$+e(&%)1 !)" '#!)#$ !e)#+ , M

3 A# &% e'#+#$##$ )e$=#$# #+%-#$ <PPT

4 A# &% e'#+#$##$ )e$=#$# #+%-#$

4 A#&%"!$(!)$#$e:#'%#+e'#+#$##$+%)= M #$ SS<

Te)##( )e%'#+ (e$(#$ e!"#$ !"%$#+ ee*

Te)##( &% e'#+#$##$ !"%$#+ ee* #$(#)#

Te)##( &% e'#+#$##$ !"%$#+ ee* e$#$

De"!)#; +e%)#$%)#$$# ##( "e$#"&#)*#$

%"#- +#( "e$e##$ $!)"#+ e$+ e'##$#$,

Te)##( &% )!+e+ e$#"##$ $!)"#+ #$ #%)#(

I$!)"#+ !$+ #+e$ #$(#)+(# '$+ (e)"#+%* PPA

Te)##( &% (e)-## #+e$ e'#+#$ -#+' #+%-#$

B'# '#%#$ $##$ "e #$ "e"e)'%*#$

Pe"&e)#$ e%#+ e## #+e$ #$ e'%#)# (e)#(

B'# e)'%#$, e"&e)#$ e%#+ *e## #+e$ #$

Te)##( &% '#%#$ :e);#+ %$(% "e"#+#$

!)"%') e%#+ (e)&#)% ) )#"#(

!)"%') e%#+ (e)&#)% ) )#"#(

A# &% e'#!)#$ e'#+#$##$ *e#(#$ PPI !'e-

%"#- +#( "e$e(##$ e)##( PPI/IP<N

A# &% e'#+#$##$ )!)#" PPI %$(%*

A# &% e'#+#$##$ )!)#" PPI %$(%*

A# &% e'#+#$##$ )!)#" PPI #$ "e'%

%"#- +#( "e$e(##$ )e%'#+ (e$(#$

%"#- +#( "e$e(##$ )+*!

A# &% e$;#+ )!+e%) #$ )!+e+ #+%-#$

%"#- +#( "e'#+#$##$ +()#(e %$(%

)+ (e'#- "e$###$ e#(#$ e'#-#$ %$(%*

%"#- +#( "e$e(##$ )+*!

A# &% "!$(!)$, e:#'%#+, #$ $# '#$%(

A# &% e'#+#$##$ +%e):+ #$ "!$(!)$