PEMERINTAH KABUPATEN CIANJUR

DINAS KESEHATAN
PUSKESMAS GEKBRONG
Alamat : Jln. Raya Cianjur – Sukabumi KM 15 Kecamatan Gekbrong Kabupaten Cianjur 43261

SURAT TUGAS
Nomor : /PKM-ST/ 2016

Yang bertanda tangan di bawah ini, Kepala Puskesmas Gekbrong Kecamatan Gekbrong Kabupaten
Cianjur, dengan ini memberikan tugas kepada yth :

Nama : Ani Rahmiati, Amd.Keb

NIP/NRPTT : 19740822 199302 2 005
Pangkat/Golongan : Penata/III.c
Jabatan : Bidan Penyelia

Tanggal : .......................................

Pembiayaan Perjalanan
Dibebankan Kepada : DPA Kegiatan BOK Dinas Kesehatan Kabupaten Cianjur
Tahun Anggaran 2016.

Demikian Surat Tugas ini di buat, untuk dapat dilaksanakan sebaik-baiknya.

Cianjur, ....................................2016
Kepala Puskesmas Gekbrong

dr. Cecep Willy Budiman

NIP. 19710915 200604 1 017

No Instansi / Kantor Tanggal Cap & Tanda Tanggal Cap & Tanda
Yang di kunjungi Datang Tangan Kembali Tangan
 LAPORAN HASIL KUNJUNGAN
1. Nama Petugas
2. Tujuan Kunjungan
3. Tempat Yang dikunjungi
4. Tanggal Perjalanan
5. Masalah Yang ditemukan
6. Saran dan tindak lanjut
Yang diusulkan
Pasien Yang Dikunjungi
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Yang Mengadakan Perjalanan
Ani Rahmiati, Amd.Keb
NIP. 19740822 199302 2 005