PEMERINTAH DAERAH KABUPATEN TASIKMALAYA

DINAS KESEHATAN DAN PENGENDALIAN PENDUDUK

UPTD PUSKESMAS MANGUNREJA
Jl. Raya Sukaraja No.51-53 Telp : (0265)544709
E-Mail : puskesmas_mangunreja@yahoo.co.id
Mangunreja - 46462

LAPORAN HASIL KEGIATAN

I. Petugas yang melaksanakan perjalanan dinas :
1. Nama : ..................................................................................................................................................
2. NIP : ..................................................................................................................................................
3. Pangkat / Golongan : ..................................................................................................................................................
4. Jabatan : ..................................................................................................................................................

II. Tanggal perjalanan dinas : ..................................................................................................................................................

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III. Tempat yang dikunjungi : ..................................................................................................................................................

Maksud perjalanan dinas : ..................................................................................................................................................

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IV. Uraian hasil perjalanan dinas :

a. Proses Pelaksanaan : ..................................................................................................................................................

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b. Permasalahan yang dihadapi : ..................................................................................................................................................

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c. Kesimpulan / Saran : ..................................................................................................................................................

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Demikian surat tugas ini dibuat untuk dilaksanakan sebaik-baiknya.

Tasikmalaya, November 2019

Yang Membuat Laporan

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