PEMERIKSAAN PERSEDIAAN OBAT-OBATAN / ALAT PPPK KAPAL

( Di isi oleh Petugas Kesehatan Pelabuhan )

Pada hari ini, ............................ tanggal : ............................ telah diadakan pemeriksaan obat-obatan /
PPPK oleh Petugas Kantor Kesehatan Pelabuhan Kelas I Tanjung Priok terhadap :

1 Nama Kapal :
2 Agen / Pemilik :
3 Bendera :
4 Jumlah Awak Kapal :
5 Jumlah Sekoci :

Pada saat pemeriksaan :

1 Kotak Obat : Ada Tidak ada
2 Jenis Obat : Lengkap Tidak lengkap
3 Jumlah Obat : Cukup Tidak cukup
4 Expire Date : Berlaku Tidak berlaku
5 Keadaan Fisik Obat : Baik Tidak baik
6 Etiket pada obat : Ada Tidak ada
7 Buku Petunjuk P3K : Ada Tidak ada
8 Alat P3K (daftar keterangan : Ada Tidak ada
alat P3K terlampir)

SARAN : 1. ................................................................................................................................
2. ................................................................................................................................
3. ................................................................................................................................
4. ................................................................................................................................
5. ................................................................................................................................

DASAR HUKUM:
1. UU RI nomor 21 tahun 1992 tentang Pelayaran
2. SK Men.Kes No. 265 tahun 2004 tentang Organisasi dan Tata Kerja KKP
3. International Medical Guide for Ships,Second Edition,WHO, 1988

Mengetahui Tanjung Priok…………………..

Nakhoda/Perwira Jaga, Petugas Pemeriksa,

(…………………………) (…................................... )
 INSPECTION OF MEDICINE SUPPLY / FIRST AIDS APPLIANCE IN SHIP.
( Content by Port Health Officer )

On this day , ….................... date of , ……………….. Have been performed by inspection of Medicine
Supply / First aids appliance by Port Health Office Class I Tanjung Priok Officer to :

1. Name of ship :
2. Agent / Owner :
3. Nationality / Flag :
4. Number of crew :
5. Number of Life boat :

at the (time) of inspection :

1 Box of Medicine : Yes No

2 Type of Medicine : Complete No
3 Number of Medicine : Enough No
4 Expire Date : Good No
5 Condition of Medicine Physical : Good No
6 Etiquette at Medicine : Yes No
7 First Aids reference book : Yes No
8 First Aids Appliance ( List enclosed ) : Yes No

Suggestion :
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
……………………………………………………………………………………………………………
…………………………………………

Legal Fundament :

1. Code No. 21,1992 about Sea Transport

2. Decree Minister of Health No. 265, 2004 about Office Administration and Organization Port Health
Office Class I Tanjung Priok
3. International Medical Guide for Ship, second Edition, WHO, 1988

Knowing Tanjung Priok, ……………………..

Master / Duty Officer Inspection Officer

( …………..…………. ) ( …………………………. )