Nama : ......................................................................................................
NIM : .............................................................
Program Studi : Ilmu Keperawatan
Judul Penelitian :
...................................................................................................................................................................
...................................................................................................................................................................
...................................................................................................................................................................
.................................................................................................................................................................
Dosen Pembimbing :
1. ...................................................................................................
2. ...................................................................................................
Tanda Tangan
Nama Laboratorium (Nama Terang Penanggung Jawab &
Stampel Lab.)
BIOMEDIK
FISIOLOGI
FARMAKOLOGI
MIKROBIOLOGI
PARASITOLOGI
PATOLOGI ANATOMI
PATOLOGI KLINIK
.................................................
Malang, ................................................
......................................................
NIP.
Nama : ..................................................................................................
NIM : ................................................................
No. Telp. / HP : ................................................................
Program Studi : IlmuKeperawatan
Judul : ..................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
Hari : ................................................................
Tanggal : ................................................................
Jam : ................................................................
Ruangan : ................................................................ (Diisi Petugas TA)
Penguji :
Nama & Golongan & Tanda
No Penguji
NIP Pangkat Tangan
1 Penguji 1
2 Penguji 2 /
Pembimbing 1
3 Penguji 3 /
Pembimbing 2
Malang, ................................................
Mahasiswa,
............................................................
NIM.
Persyaratan Pendaftaran:
1. Pas photo ukuran 3 x 4 berwarna menggunakan almamater sebanyak 1 lembar (Tulis nama & NIM
dibelakang foto)
2. Fotocopy Kartu Tanda Mahasiswa (KTM) semester terakhir (1 lembar)
3. Lembar Persetujuan Ujian Tugas Akhir (Form TA 08)
4. Form penilaian Log Book (dari dua dosen pembimbing)
5. Lembar Konsultasi asliuntuk Tim TA yang fotocopy untuk diberikan ke Pembimbing (Form TA 04)
(minimal 10x bimbingan untuk masing-masing dosen)
6. Formulir Bebas Tanggungan Laboratorium (Form TA 07)
7. Formulir pendaftaran Ujian Sidang Tugas Akhir (Form TA 09)
8. Lembar Persetujuan yang ditandatangani kedua Pembimbing sebanyak (1 lembar)
9. Foto Copy KHS terakhir (1 lembar)
10. Printout KRS online terakhir (1 lembar)
11. Lembar bukti kelayakan etik (1 lembar)
12. Lembar Bukti Pendaftaran Tugas Akhir
13. Kuitansi asli pembayaran Tugas Akhir (Pembayaran di Bank BNI)(2 lembar, satu asli dan satu fotocopy)
14. Naskah TA (1 eksemplar)
15. Map bufalo warna hijau (PD), kuning (PSIK), biru (PSIG), pink (PS S1Keb), sebanyak 4 lembar
Malang, ......................................
................................................. ..................................................
NIP. NIM.
“ Semua PersyaratanUjian TA minimal 1 Minggu sebelum ujian berlangsung harus sudah terkumpul ke Petugas TA”
embimbing 1
NAMA MAHASISWA :
NIM :
NAMA PEMBIMBING 1 :
JUDUL TUGAS AKHIR :
Malang,......................
Mengetahui,
Pembimbing1,
...................................................
NIP.
Pembimbing 2
NAMA MAHASISWA :
NIM :
NAMA PEMBIMBING 2 :
JUDUL TUGAS AKHIR :
Malang, ..........................................
Mengetahui,
Pembimbing2,
...........................................................
NIP.