PEMERINTAH KABUPATEN PACITAN

DINAS KESEHATAN
PUSKESMAS KALAK
Alamat : RT 04 RW 02 Dusun Krajan Kulon, Desa Kalak, Kec.Donorojo
Telp : 082230276971 Email : puskesmaskalak.pacitan@gmail.com

LAPORAN PERJALANAN DINAS

1. Dasar :

2. Tempat tujuan :

3. Tanggal Kunjungan :

4 Unit kerja yang dikunjungi

Nama :

Jabatan :

5. Tujuan Kunjungan :

6 Hasil Kunjungan :

7 Saran yang diberikan :

Yang dikunjungi Yang Melaksanakan Tugas

.................................................... ………………………………
NIP…………………………….
akan Tugas

………………
…………….
 PEMERINTAH KABUPATEN PACITAN
DINAS KESEHATAN
PUSKESMAS KALAK
Alamat : RT 04 RW 02 Dusun Krajan Kulon, Desa Kalak, Kec.Donorojo
Telp : 082230276971 Email : puskesmaskalak.pacitan@gmail.com

DAFTAR HADIR

Hari :................................................................................................................................
Tanggal :................................................................................................................................
Waktu :................................................................................................................................
Tempat :................................................................................................................................
Acara :................................................................................................................................

NO NAMA ASAL TANDA TANGAN KET

1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
11 11
12 12
13 13
14 14
15 15
16 16
17 17
18 18
19 19
20 20
21 21
22 22
23 23
24 24
25 25
26 26
27 27
28 28
29 29
30 30
 PEMERINTAH KABUPATEN PACITAN
DINAS KESEHATAN
PUSKESMAS KALAK
Alamat : RT 04 RW 02 Dusun Krajan Kulon, Desa Kalak, Kec.Donorojo
Telp : 082230276971 Email : puskesmaskalak.pacitan@gmail.com

NOTULEN

NAMA KEGIATAN :..................................................................................................

HARI/TANGGAL KEGIATAN :..................................................................................................

JAM KEGIATAN :..................................................................................................

LOKASI KEGIATAN :..................................................................................................

SASARAN KEGIATAN :..................................................................................................

SUSUNAN ACARA :1...............................................................................................

2...............................................................................................

3................................................................................................
4...............................................................................................

5...............................................................................................

6..............................................................................................

7..............................................................................................

8...............................................................................................

PIMPINAN KEGIATAN

KETUA :.................................................................................................

NOTULIS :................................................................................................

PESERTA : (terlampir dalam daftar hadir)

1. Pembukaan

2.Notulen Sebelumnya
3.Pembahas
4.Diskusi

5.Rencana Tindak Lanjut

Mengetahui
KEPALA PUSKESMAS KALAK Pelaksana Kegiatan

dr.DWI HEPPY KRESNAWANTO ……………………………………………

NIP.19750622 201001 1 007 NIP.