RKA DAK KESEHATAN 2014 ACEH

SUBBIDANG PELAYANAN KESEHATAN RUJUKAN SUMATE

SUMATE

Prov : SULAWESI TENGAH RIAU

KAB/Kota : Kab. Tojo Una-Una KEPULAU
Nama RS : RSU Ampana JAMBI
SUMATE

Identitas Direktur Rumah Sakit Identitas Peserta Desk Identitas Dinas Kesehatan Provinsi BANGKA
Nama : dr. Hans Tunggadi Nama : Wahidin R. Sako, S.Kep, Ns Nama : Bambang SP Suwandi, SKM, MBENGKU
NIP : 195709111985121001 NIP : 197901012000121006 NIP : 196411231991011001 LAMPUN

No. Hp : 081244317057 Jabatan : Ka.Subag Perencanaan & Progr Jabatan : Sekretaris Dinas Kesehatan JAWA BA
Email : rsu_ampana@yahoo.com No. Hp : 085241311179 No. Hp : 0811456496 BANTEN

Email : wahidin_sako@yahoo.co.id Email : bambangsetyosuwandi@gmail.com JAWA TE

DI YOGY
JAWA TIM
KALIMAN
KALIMAN

PAGU : 1,537,560,000 KALIMAN

DANA PENDAMPING : 153756000 KALIMAN

TOTAL : 1,691,316,000 SULAWE

GORONT

RKA DAK 2014 SULAWE

Usulan
No Menu
Rakontek Pilihan Kegiatan Unit Cost Jumlah SULAWE

Bangunan T 1 Rp 605,749,250 Rp 605,749,250 SULAWE

1 TT Klas III
Alat Y 1 Rp437,250,000 Rp437,250,000 SULAWE
Bangunan T Rp0 BALI
2 IGD RS
Alat Y 1 Rp0 Rp0 NTB
Bangunan T Rp0 NTT
3 ICU RS
Alat Y 1 Rp422,070,500 Rp422,070,500 MALUKU
Bangunan T Rp0 MALUKU
4 RS SIAP PONEK
Alat T 1 Rp1,232,810,250 Rp1,232,810,250 PAPUA
Bangunan T 0 Rp0 PAPUA B
5 IPAL
Alat T 0 Rp0 Kab. Karo
Bangunan T 0 Rp0 Kab. Lab
6 PENGOLAH LIMBAH PADAT
Alat T 0 Rp0 Kab. Lan
Bangunan T 0 Rp0 Kab. Man
BDRS
Alat T 0 Rp0 Kab. Nias
7 Pelayanan Darah
Bangunan T Rp0 Kab. Sim
UTD di RS
Alat Y 1 Rp625,000,000 Rp625,000,000 Kab. Tap
Bangunan - Rp0 Kab. Tap
8 ALAT KALIBRASI
Alat T 1 Rp0 Kab. Tap

TOTAL Rp3,322,880,000 Kab. Tob

Kota Binj

Saya menyatakan bahwa data yang disampaikan adalah benar sesuai kondisi lapangan dan dapat dipertanggungjawabkan. Kota Med

Kota Pem
Biro Perencanaan dan Anggaran Mengetahui, Jakarta, 26/01/2022 Kota Sibo

Kementerian Kesehatan Dinas Kesehatan Provinsi RSU Ampana Kota Tan

Kota Teb
Kota Pad

Bambang SP Suwandi, SKM, M. Kes dr. Hans Tunggadi Kab. Pak

NIP : NIP : 196411231991011001 NIP : 195709111985121001 Kab. Nias
 Nama Nama
Kab/ Rumah Nama
Provinsi NIP No HP Email Peserta NIP Jabatan No HP Email Dinkes NIP
Kota Sakit Direktur RS
Desk Prov

SULAWESI Kab. Tojo RSU Ampana dr. Hans Tungga195709111081244317rsu_ampanWahidin R.197901012Ka.Subag P085241311wahidin_s Bambang SP
196411231
 TT Klas III

Bangunan
Dana RKA DAK 2014
Jabatan No HP Email Pagu Pendampin Total
g Usulan
Rakontek Pilihan
Unit Cost Jumlah
Kegiatan

Sekretaris 081145649bambangse 1,537,560,000 153756000 1,691,316,000 T 1 605749250 605749250

TT Klas III IGD RS

Alat Bangunan Alat

RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan Usulan

Rakontek Pilihan Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan Kegiatan

Y 1 437250000 437250000 T 0 0 0Y 1
 ICU RS

Alat Bangunan Alat

RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan
Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan

0 0T 0 0 0Y 1 422070500 422070500
 RS SIAP PONEK

Bangunan Alat Bangunan

RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan Usulan

Rakontek Pilihan Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan Kegiatan

T 0 0 0T 1 1232810250 1232810250 T 0
 IPAL PENGOLAH LIMBAH PADAT

Bangunan Alat Bangunan

RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan
Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan

0 0T 0 0 0T 0 0 0
GOLAH LIMBAH PADAT
BDRS
Alat Bangunan Alat
RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan Usulan

Rakontek Pilihan Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan Kegiatan

T 0 0 0T 0 0 0T 0
 Pelayanan Darah
UTD di RS
Alat Bangunan Alat
RKA DAK 2014 RKA DAK 2014 RKA DAK 2014

Usulan Usulan
Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan

0 0T 0 0 0Y 1 625000000 625000000
 ALAT KALIBRASI

Bangunan Alat
RKA DAK 2014 RKA DAK 2014
TOTAL
Usulan Usulan
Rakontek Pilihan Rakontek Pilihan
Unit Cost Jumlah Unit Cost Jumlah
Kegiatan Kegiatan

- 0 0 0T 1 0 0
 REKAP KEBUTUHAN ANGGARAN
DANA ALOKASI KHUSUS BIDANG KESEHATAN RUJUKAN
RSUD AMPANA KAB. TOJO UNA-UNA
TAHUN ANGGARAN 2015

PENDAMPING Kewajaran dan

NO NAMA ALAT VOLUME SATUAN HARGA SUB TOTAL / PPN 10% ongkir (15%) TOTAL KET

Tempat Tidur Kelas III

1 Tempat Tidur Kelas III 15 UNIT 26,500,000 397,500,000 39,750,000 3,975,000 437,250,000
26,500,000 397,500,000 39,750,000 3,975,000 437,250,000
ALAT PONEK (Kebidanan)
1 Partus Set 3 UNIT 42,000,000 126,000,000 0 18,900,000 144,900,000 Sudah Masuk PPN
2 Curetage Set 1 UNIT 103,000,000 103,000,000 0 15,450,000 118,450,000 Sudah Masuk PPN
3 Incubator Transport 1 UNIT 0 0 0 0 0 Sudah Masuk PPN
4 Infus pump Sudah Masuk PPN
5 Ventilator Neonatus 1 UNIT 0 0 0 0 0 Sudah Masuk PPN
6 UV Room Sterilizer 1 UNIT 61,500,000 61,500,000 0 9,225,000 70,725,000 Sudah Masuk PPN
7 Hecting Set 3 UNIT 34,000,000 102,000,000 0 15,300,000 117,300,000 Sudah Masuk PPN
8 Monitor Pasien 1 UNIT 111,335,000 111,335,000 0 16,700,250 128,035,250 Sudah Masuk PPN
9
351,835,000 503,835,000 0 75,575,250 579,410,250 Sudah Masuk PPN
ALAT PONEK (Kamar Bayi)
1 Infan Warmer 1 UNIT 287,000,000 287,000,000 0 43,050,000 330,050,000 Sudah Masuk PPN
2 Phototerapy LED 1 UNIT 131,000,000 131,000,000 0 19,650,000 150,650,000 Sudah Masuk PPN
3 Incubator 2 UNIT 65,600,000 131,200,000 0 131,200,000 E Katalog
4 Syrenge Pump (Terumo TE-332CW3S) 1 UNIT 18,500,000 18,500,000 0 18,500,000 E Katalog
5 Infus Pump (Terumo TE-172CW3) 1 UNIT 23,000,000 23,000,000 0 23,000,000 E Katalog
6
7
8
9
525,100,000 590,700,000 0 62,700,000 653,400,000

TOTAL ALAT PONEK 1,094,535,000 138,275,250 1,232,810,250

INSTALASI GAWAT DARURAT (IGD)

1 Timbangan Bayi 2 UNIT 0 0 0 0 0
2 Timbangan Dewasa 2 UNIT 0 0 0 0 0
8 Sterilisator ruangan (UV) 1 UNIT 0 0 0 0 0
0 0 0 0 0
INTENSIF CARE UNIT (ICU)
1 Monitor Pasien 2 UNIT 111,335,000 222,670,000 0 33,400,500 256,070,500
2 Syrenge Pump (Terumo TE-332CW3S) 4 UNIT 18,500,000 74,000,000 0 74,000,000 E Katalog
3 Infus Pump (Terumo TE-172CW3) 4 UNIT 23,000,000 92,000,000 0 92,000,000 E Katalog
4 Tempat Tidur ICU 4 UNIT 0 0 0 0 0
5 Troly Tindakan 1 UNIT 0 0 0 0 0
152,835,000 388,670,000 0 33,400,500 422,070,500
UNIT TRANSFUSI DARAH RUMAH SAKIT (UTDRS)
1 Centrifuse Referigator Kecil 1 UNIT 500,000,000 500,000,000 50,000,000 75,000,000 625,000,000
500,000,000 500,000,000 50,000,000 75,000,000 625,000,000

REHABILITASI PERAWATAN INTERNA

1 Rehabilitasi R. Inap Kelas III (Fisik) 1 Paket 550,000,000 550,000,000 0 0 550,000,000
2 Rehabilitasi R. Inap Kelas III (Perencanaan) 1 Paket 33,500,000 33,500,000 0 0 33,500,000
1 Rehabilitasi R. Inap Kelas III (Pengawasan) 1 Paket 22,249,250 22,249,250 0 0 22,249,250
605,749,250 605,749,250 0 0 605,749,250

56 2,162,019,250 2,986,454,250 89,750,000 250,650,750 3,322,880,000

Ampana 01 November 2014

Direktur RSUD Ampana

dr. Josevien Manuputty

NIP. 19610917 198812 2 001
 REKAP PERMINTAAN ALAT KESEHATAN MEDIK
UNTUK DANA ALOKASI KHUSUS BIDANG KESEHATAN RUJUKAN
RSUD AMPANA KAB. TOJO UNA-UNA
TAHUN ANGGARAN 2015

Pendamping 10 %
satuan Pihak ketiga 15 % Total
Nomor Nama Kegiatan Pagu

29,150,000.00 1 Pengadaan Tempat Tidur Kelas III ( 15 Set )

Pengadaan Tempat Tidur Set Kelas III (DAK) 397,500,000 39,750,000 437,250,000

48,300,000.00 2 Pengadaan Alat Kesehatan ( 1 Paket )

118,450,000.00 a. Pengadaan Alkes Ponek, IGD, ICU dan UTDRS
- - Ponek 1,094,535,000 138,275,250 1,232,810,250 164,180,250
- IGD - - -
- ICU 388,670,000 38,867,000 427,537,000
70,725,000.00 - UTDRS 500,000,000 125,000,000 625,000,000
39,100,000.00 - Rehab perawatan Interna 605,749,250 - 605,749,250
128,035,250.00 2,588,954,250 302,142,250 2,891,096,500

3 b. Pengadaan Alat Kalibrasi untuk Alat kesehatan ( 1 Paket )

- Digital Preasure Meter 65,000,000 6,500,000 71,500,000
330,050,000.00 - Patient Simulator 45,000,000 4,500,000 49,500,000
150,650,000.00
110,000,000 11,000,000 121,000,000

3,096,454,250 352,892,250 3,449,346,500

3,449,346,500

TT ALKES Alat Kalibrasi

0 Ponek 0 0
IGD 256,070,500
ICU 0
UTDRS 22,249,250

0 278,319,750 0 278,319,750

1363499500
625,000,000.00

Jakarta 485,600,000.00
675,000,000.00 PPN 48,560,000.00
47,250,000.00
33,605,000.00 Pihak 3 72,840,000.00
Ongkir 24,280,000.00
Total 631,280,000.00

63,128,000.00
 REKAP PERMINTAAN ALAT KESEHATAN MEDIK
UNTUK DANA ALOKASI KHUSUS BIDANG KESEHATAN RUJUKAN
RSUD AMPANA KAB. TOJO UNA-UNA
TAHUN ANGGARAN 2014

NO NAMA ALAT VOLUMESATUAN HARGA SUB TOTAL PENDAMPING TOTAL

Tempat Tidur Kelas III

1 Tempat Tidur Kelas III 10 UNIT 20,725,000 207,250,000 20,725,000 227,975,000

20,725,000 207,250,000 20,725,000 227,975,000

ALAT PONEK (Kebidanan)
1 Fetal Dopler with LCD 1 UNIT 8,600,000 8,600,000 860,000 9,460,000
2 Penghangat darah (blood warmer) 1 UNIT 60,000,000 60,000,000 6,000,000 66,000,000
3 Obgyn Bed 1 UNIT 253,540,000 253,540,000 25,354,000 278,894,000
4 Lampu sorot Ginekolog 1 UNIT 36,220,000 36,220,000 3,622,000 39,842,000
5 Curetase set 1 SET 91,060,000 91,060,000 9,106,000 100,166,000

449,420,000 449,420,000 44,942,000 494,362,000

ALAT PONEK (Kamar Bayi)
1 Inkubator Baby 1 UNIT 114,120,000 114,120,000 11,412,000 125,532,000
2 Infant resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
3 Neonatus resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
4 Stetoskop Infant 2 UNIT 1,600,000 3,200,000 320,000 3,520,000

151,280,000 152,880,000 15,288,000 168,168,000

TOTAL ALAT PONEK 602,300,000 662,530,000

INSTALASI GAWAT DARURAT (IGD)

1 Laringoskop Dewasa 2 SET 11,270,000 22,540,000 2,254,000 24,794,000
2 Laringoskop Anak 2 SET 11,270,000 22,540,000 2,254,000 24,794,000
3 Tensimeter Berdiri 1 UNIT 11,500,000 11,500,000 1,150,000 12,650,000
4 Infant resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
5 Adult resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
6 Vena sectio Set 1 SET 31,380,000 31,380,000 3,138,000 34,518,000
7 Brankar Transport 1 UNIT 11,077,000 11,077,000 1,107,700 12,184,700
8 Kursi Roda (Whell Chair) 2 UNIT 4,155,000 8,310,000 831,000 9,141,000
9 Stetoskop Dewasa 2 UNIT 740,000 1,480,000 148,000 1,628,000
10 Stetoskop Anak 2 UNIT 1,700,000 3,400,000 340,000 3,740,000

118,652,000 147,787,000 14,778,700 162,565,700

INTENSIF CARE UNIT (ICU)
1 Defibrilator 1 UNIT 181,238,000 181,238,000 18,123,800 199,361,800
5 Lampu Sorot 1 UNIT 36,220,000 36,220,000 3,622,000 39,842,000
8 Tensi Meter Berdiri 2 UNIT 11,500,000 23,000,000 2,300,000 25,300,000

228,958,000 240,458,000 24,045,800 264,503,800

UNIT TRANSFUSI DARAH RUMAH SAKIT (UTDRS)
1 Tempat Tidur Donor 2 UNIT 12,000,000 24,000,000 2,400,000 26,400,000
2 Blood bank Referigator (Kulkas Penyimpan Da 1 UNIT 225,000,000 225,000,000 22,500,000 247,500,000

237,000,000 249,000,000 24,900,000 273,900,000

ALAT KALIBRASI
1 Digital Preasure Meter 1 UNIT 57,000,000 57,000,000 5,700,000 62,700,000
2 Patient Simulator 1 UNIT 33,765,000 33,765,000 3,376,500 37,141,500

90,765,000 90,765,000 9,076,500 99,841,500

1,296,800,000 1,537,560,000 153,756,000 1,691,316,000

1,537,560,000 1,691,316,000
1,691,316,000
- -
Nomor Nama Kegiatan Pagu Pendamping Total

1 Pengadaan Tempat Tidur Kelas III ( 10 Set )

Pengadaan Tempat Tidur Set Kelas III (DAK) 207,250,000 20,725,000 227,975,000

2 Pengadaan Alat Kesehatan ( 1 Paket )

a. Pengadaan Alkes Ponek, IGD, ICU dan UTDRS
- Ponek 602,300,000 60,230,000 662,530,000
- IGD 147,787,000 14,778,700 162,565,700
- ICU 240,458,000 24,045,800 264,503,800
- UTDRS 249,000,000 24,900,000 273,900,000

1,239,545,000 123,954,500 1,363,499,500

3 b. Pengadaan Alat Kalibrasi untuk Alat kesehatan ( 1 Paket )

- Digital Preasure Meter 57,000,000 5,700,000 62,700,000
- Patient Simulator 33,765,000 3,376,500 37,141,500

90,765,000 9,076,500 99,841,500

1,537,560,000 153,756,000 1,691,316,000

1,691,316,000

TT ALKES Alat Kalibrasi

227,975,000 Ponek 662,530,000 99,841,500

IGD 162,565,700
ICU 264,503,800
UTDRS 273,900,000

227,975,000 1,363,499,500 99,841,500 1,691,316,000

1363499500
220
22
 REKAP PERMINTAAN ALAT KESEHATAN MEDIK
UNTUK DANA ALOKASI KHUSUS BIDANG KESEHATAN RUJUKAN
RSUD AMPANA KAB. TOJO UNA-UNA
TAHUN ANGGARAN 2014

NO NAMA ALAT VOLUME SATUAN HARGA SUB TOTAL PENDAMPING TOTAL

Tempat Tidur Kelas III Incubator

1 Tempat Tidur Kelas III 10 UNIT 20,725,000 207,250,000 20,725,000 227,975,000 syrenge pump
Infus pump
20,725,000 207,250,000 20,725,000 227,975,000
ALAT PONEK (Kebidanan)
1 Fetal Dopler with LCD 1 UNIT 8,600,000 8,600,000 860,000 9,460,000
2 Pulse Oximetri dewasa 2 UNIT 0 0 0
3 Monitor denyut jantung / pernafasan 1 UNIT 0 0 0
4 Penghangat darah (blood warmer) 1 UNIT 60,000,000 60,000,000 6,000,000 66,000,000 252
5 Syringe pump 1 UNIT 0 0 0
6 Infus pump 1 UNIT 0 0 0
7 Kotak Resusitasi 2 UNIT 0 0 0
8 USG Portable 1 UNIT 0 0 0
9 UPS 1 UNIT 0 0 0
10 Obgyn Bed 1 UNIT 253,540,000 253,540,000 25,354,000 278,894,000
11 Sterilisator Kering 1 UNIT 0 0 0
12 Lampu sorot Ginekolog 1 UNIT 36,220,000 36,220,000 3,622,000 39,842,000
13 Curetase set 1 SET 91,060,000 91,060,000 9,106,000 100,166,000

449,420,000 449,420,000 44,942,000 494,362,000

ALAT PONEK (Kamar Bayi)
1 Inkubator Baby 1 UNIT 114,120,000 114,120,000 11,412,000 125,532,000
2 Infant Warmer 2 UNIT 0 0 0
3 Pulse Oximetri neonatus 3 UNIT 0 0 0
4 Phototherafy 2 UNIT 0 0 0
5 Syringe Pump 4 UNIT 0 0 0
6 Infant resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
7 Continous Positive airway presure (CPAP) 1 UNIT 0 0 0
8 Flow meter 1 UNIT 0 0 0
9 Infus pump 1 UNIT 0 0 0
10 Neonatus resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
11 Sterilisator ruangan (UV) 1 UNIT 0 0 0
12 Sterilisator alat (UV) 1 UNIT 0 0 0
13 Stetoskop Infant 2 UNIT 1,600,000 3,200,000 320,000 3,520,000

151,280,000 152,880,000 15,288,000 168,168,000

TOTAL ALAT PONEK 602,300,000 662,530,000

INSTALASI GAWAT DARURAT (IGD)

1 Laringoskop Dewasa 2 SET 11,270,000 22,540,000 2,254,000 24,794,000
2 Laringoskop Anak 2 SET 11,270,000 22,540,000 2,254,000 24,794,000
3 Tensimeter Berdiri 1 UNIT 11,500,000 11,500,000 1,150,000 12,650,000
4 Infant resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
Adult resusitacion & emergency set 1 UNIT 17,780,000 17,780,000 1,778,000 19,558,000
5 Vena sectio Set 1 SET 31,380,000 31,380,000 3,138,000 34,518,000
6 Timbangan Bayi 1 UNIT 0 0 0
7 Brankar Transport 1 UNIT 11,077,000 11,077,000 1,107,700 12,184,700
8 Kursi Roda (Whell Chair) 2 UNIT 4,155,000 8,310,000 831,000 9,141,000
9 Stetoskop Dewasa 2 UNIT 740,000 1,480,000 148,000 1,628,000
10 Stetoskop Anak 2 UNIT 1,700,000 3,400,000 340,000 3,740,000

118,652,000 147,787,000 14,778,700 162,565,700

INTENSIF CARE UNIT (ICU)
1 Defibrilator 1 UNIT 181,238,000 181,238,000 18,123,800 199,361,800
2 Jackson Rise 1 SET 0 0 0
3 Timbangan Dewasa 1 UNIT 0 0 0
4 Timbangan Bayi 1 UNIT 0 0 0
5 Lampu Sorot 1 UNIT 36,220,000 36,220,000 3,622,000 39,842,000
6 Tempat Tidur ICU 4 UNIT 0 0 0
7 Troly Tindakan 1 UNIT 0 0 0
8 Tensi Meter Berdiri 2 UNIT 11,500,000 23,000,000 2,300,000 25,300,000
 228,958,000 240,458,000 24,045,800 264,503,800
UNIT TRANSFUSI DARAH RUMAH SAKIT (UTDRS)
1 Tempat Tidur Donor 2 UNIT 12,000,000 24,000,000 2,400,000 26,400,000
2 Blood bank Referigator (Kulkas Penyimpan Darah) 1 UNIT 225,000,000 225,000,000 22,500,000 247,500,000
3 Centrifuse Referigator Kecil 1 UNIT 0 0 0

237,000,000 249,000,000 24,900,000 273,900,000

ALAT KALIBRASI
1 Digital Preasure Meter 1 UNIT 57,000,000 57,000,000 5,700,000 62,700,000
2 Patient Simulator 1 UNIT 33,765,000 33,765,000 3,376,500 37,141,500

90,765,000 90,765,000 9,076,500 99,841,500

1,296,800,000 1,537,560,000 153,756,000 1,691,316,000

1,537,560,000 1,691,316,000
1,691,316,000
1,681,000,000.00 - -

10,316,000.00
 385,000,000.00
4.00 38,000,000.00 152,000,000.00
5.00 18,500,000.00 92,500,000.00
6.00 23,000,000.00 138,000,000.00

382,500,000.00
2,500,000.00
220
22