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APLIKASI KREDENSIALING KEPERAWATAN

 A. IDENTITAS
Nama Pemohon
: ...................................................................................................
NIP/
NIP/NI NIK
K : ....
......
....
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....
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....
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....
....
....
....
....
..
........
Tangga
nggall Lahi
Lahirr : ....
.......
.....
....
../..
/....
....
.....
..../
./..
.....
.....
....
....
.. (tanggal/bulan/tahun)
tanggal/bulan/tahun)
Mulai kerja
kerja di RSDK : .........../........../........... (tanggal/bulan/tahun
(tanggal/bulan/tahun))
Ruang :........................................E!en"io
No :.....................................
Tele#on : .................................
$P : ............................................
Emai
Emaill : ....
......
....
....
....
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....
....
....
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....
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....
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....
....
........
......
........
......
........
......
......
.......

B. STATUS
STATUS REGISTRASI (saat ini)
Nomor Regi"!ra"i
: ..............................................................................
Nomor Ija%ah
: ..............................................................................
Nama In"!i!u"i Pendidikan
: ..............................................................................
Tanggal
Tanggal Lulu"
: ..............................................................................
Kuali&ik
&ika"i Pe Pendidikan : Di
Di#loma/Ne /Ner"/ S# S#e"iali"................
............
........
Penjenjangan Karir : PK ' / I / II / III /
I / ..............................................
Nomor "er!i&ika! kom#e!en"i
: ..............................................................................
Ma"a erlaku "am#ai : ........./........../........... (tanggal/bulan/tahun

C. STATUS
STATUS KREDENSIALING
KREDENSIALI NG YANG DIUSULKAN(Berikan
DIUSULKAN (Berikan ceklist pada salah
satu kotak) 
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Ke+enangan
 *+al  Kenaikan !ingka!  Pemulihan Useful  Not
useful
........................
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Form Kredensial Perawat

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......*#akah ke+enangan klini" anda #ernah :
• Dikurangi 0a Tidak
• Diekukan 0a Tidak
• Di2au! 0a Tidak
ika0a1 !uli"kan ka#an hal !er"eu! !erjadi.
..................................................................................................................
......
3. *#akah anda #ernah menda#a! !eguran / #eminaan di"i#lin dari a!a"an
0a Tidak
..................................................................................................................
...

4. Tuli"kan ke+enangan klini" -ang diu"ulkan e"er!a uk!i5uk!i #enduku

("e"uai uku #u!ih)

No KewenanganKlinis Yang Diinginkan BktiPen!kng

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5. Tuli"kan #rogram #engemangan #ro&e""ional erkelanju!an (6PD) a

#era+a! -ang anda iku!i dalam 3 !ahun !erakhir 

7uk!i
Tahun (Nomor  In"!i!u"i
Kegia!a Sertifikat/  Pen-elenggara eni" Kegia!an
n Surat  Kegia!an
Tugas/SK)

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 Sheet Music Tanda Tangan : ................................................................

Nama ela" : ................................................................. (Tulis denga

huruf cetak)

Tanggal : ........./........../.......... (Tanggal/Bulan/Tahun)

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PR#SES KREDENSIALING KEPERAWATAN

A. I!entitas

NamaPera+a! : .........................................................................
.........

Kuali&ika"i : PK '/ I up
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III / I
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Tanggal : ........................................................................
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%. Da&ta" Kewenangan Klinik Yang Dislkan

Ke+enangan klinik dierikan ke#ada "e!ia# #era+a! "e"uai jenjang karir1 #er
dilakukan kreden"ial !erhada# ke+enangan klini" un!uk mem#er
#enuga"an klinik. Penuga"an klinik -ang dierikan dalam rangka memerika
a"uhan ke#era+a!an di RS kariadi un!uk memenuhi keu!uhan da"ar #a"ie
dan keluarga. Pro"e" kreden"ial dimulai dengan #era+a! "e2ara
menggamarkan kemam#uan "aa! ini dengan kri!eria :
, 9 Kom#e!en 8 9 Dengan Su#eri"i 3 9 7elum Kom#e!en
Selanju!n-a Su Komi!e Kreden"ial er"ama Mi!ra 7e"!ari melaku
kreden"ial dengan ha"il :
, 9 7er+enang Penuh 8 9 Dengan Su#eri"i 3 9 7ukan Ke+enangan
Selanju!n-a rekomenda"i diua! !erhada# "e!ia# ke+enangan klini" (6P
dengan kri!eria :
S 9 Se!uju TS 9Tidak Se!uju
Ke+enangan klini" #era+a! klinik : ' / I / II / III / I
..............................................
;n!uk keahlian ke#era+a!an: You're Reading a Preview
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Medikal Emergen"i/ Kri!ikal
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................................

Pro"e" Kreden"ialing

N Kemam#ua Reie+ Rekomenda"

Ke+enangan Klini"0ang Dimin!a
o n Saa! ini / i
alida" 
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i S TS
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Silahkan menamahkan #ada

halaman lain jika kolom ini !idak
men2uku#i
 elakkanTin!akanKola*o"asi

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Silahkan menamahkan #ada

halaman lain jika kolom ini !idak
men2uku#i
+ elakkan Pen!i!ikan
Kese,atan

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Silahkan menamahkan #ada

halaman lain jika kolom ini !idak
men2uku#i 
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Catatan oleh Ketua Sub Komite Kredensial
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Besta"i 
NamaTandaTangan
,. <<<<< ,. <<<<
8. <<<<<.8. <<
+.  <<<<<.3. <<<<

Catatan : Pe"awatKlinik 
Nama :.................<<<

TandaTangan: <<<<<
Tanggal :......................

E. Pe"set/an

Keta S* Ko$ite K"e!ensial

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Nama : ......................................................................
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: ......................................................................
Tanggal : ......................................................................

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