PEMERINTAH DAERAH KABUPATEN SELUMA

DINAS KESEHATAN
UPT PUSKESMAS BABATAN
Alamat : Jln. Raya Bengkulu-Seluma KM.19 Kel. Babatan Kec. Sukaraja

LAPORAN PELAKSANAAN TUGAS

1. Dasar Penugasan : /PKMBBT/BOK/ /2018

2. Nama Petugas/ TIM : 1).....................................
2).....................................
3).....................................
3. Tujuan Perjalanan : ........................................
4. Tanggal Perjalanan : ........................................
5. Maksud Perjalanan : Melaksanakan Kegiatan Pengawasan Makanan/Jajanan
di Sekolah
6. Pejabat yang Ditemui : Kepala Sekolah..............................................
7. Hasil Kunjungan :
a. Proses Pelaksanaan :
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b. Permasalahan yang Dihadapi:
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c. Kesimpulan/ Saran Perbaikan:
...................................................................................................................................
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Kepala Sekolah...................... Petugas
1) ............................................
2) ............................................
............................................... 3) ............................................
NIP: ......................................

KEPALA UPT PUSKESMAS BABATAN

RATNA SARI DEWI, SKM

NIP : 19690929 199101 2 001