Form 11.01.

60
POLTEKKES KEMENKES SURABAYA DAFTAR : ABSENSI PRAKTEK KLINIK
JURUSAN KEPERAWATAN RUANGAN :
PROGRAM STUDI D.3 KEPERAWATAN SIDOARJO PERIODE :
JL. PAHLAWAN NO. 173-A SIDOARJO ( 031) 8921789

TGL TGL TGL TGL TGL TGL TGL

NO NAMA DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG DATANG PULANG
JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD JAM/TTD

Sidoarjo,
Kepala Ruangan

NIP.
 BERITA ACARA PRAKTEK
Nomor : Form. 11.01.61

Pada hari ini ................................. Tanggal. .......................... Bulan ........................ Tahun Dua Ribu ....................
telah dilakukan Praktek Keperawatan Semester ...................... Program Studi D 3 Keperawatan
Sidoarjo Jurusan Keperawatan Politeknik Kesehatan Kemenkes Surabaya
Tahun Akademik .................................................. Di Ruang .................................... RS. .....................................

Kejadian selama Ujian ............................................................................................................................................

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Nama Peserta Ujian : NIM :

1. .......................................................................................... ...................................................................

2. .......................................................................................... ..................................................................

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10. .......................................................................................... ...................................................................

Demikian berita acara ini dibuat dengan sebenarnya untuk dapat dipergunakan sebagaimana mestinya

PEMBIMBING NIP / TANDA TANGAN

Sidoarjo,
Mengetahui
Ketua Program Studi D.3 Keperawatan
Sidoarjo

Suprianto, S.Kep,Ns,M.Psi
NIP. 197306161998031002
 KEMENTERIAN KESEHATAN RI
POLITEKNIK KESEHATAN KEMENKES SURABAYA
Politeknik Kesehatan Kemenkes Surabaya DAFTAR : Hadir praktek Mahasiswa
Prodi D.3 Keperawatan Sidoarjo Prodi D.3 Keperawatan Sidoarjo
Jl. Pahlawan No. 173 A Sidoarjo ( Kelas )
TK. /Smt : ...............................
T.A : ...............................
Ruang RS : .................................
Form : 11.01.57
NOMOR Ttd
NAMA MAHASISWA Hari / Tangal Ttd Penguji
URT INDUK Penguji

10

Sidoarjo
Mengetahui
Ketua Program Studi D 3 Keperawatan
Sidoarjo

Suprianto, S.Kep,Ns.M.Psi
NIP.19730616998031002