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PEMERINTAH KABUPATEN LUMAJANG

DINAS KESEHATAN
UPT PUSKESMAS KEDUNGJAJANG
Jl. Raya Kedungjajang 118 Telp ( 0334 )441627
email : puskesmaskedungjajang22@gmail.com
LUMAJANG – 67358

LAPORAN

Kepada : .................................................................................
Dari : .................................................................................
Nomor : ......................................................................................
Perihal : .....................................................................................
Pelaksanaan : .....................................................................................
Tempat : ..................................................................................
HasilKegiatan :

a. Proses Kegiatan

Hari/tangga
No Kegiatan Hasil ParafPembimbing
l

Hari/tangga
No Kegiatan Hasil ParafPembimbing
l
b. Permasalahan yang dihadapi
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Kedungjajang, 2019
NAMA PEMBUAT LAPORAN,

……………………………..
NIP.

LAMPIRAN

No Nama Barang Jumlah Rusak Tidak Rusak


1 Arsip laporan Bulanan 1 bandel v
2 Format Laporan Bulan 1 bandel v
3 Register khor bayi,ibu, 1 v
anak, dan KB

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