KARTU PENDAFTARAN SDM LINI LAPANGAN

K/0/PKB/20
PETUGAS LAPANGAN KB DAN PENYULUHAN KB

B
Kode Provinsi Kode Kabupaten/ Kode Tenaga Nomor Register
Kota Program PKB/PLKB

1. NAMA :
2. TANGGAL LAHIR :
3. ALAMAT
a. Jalan :
b. Desa/Kelurahan :
c. Kecamatan :
d. Kabupaten/Kota :
e. Provinsi :
f. No. HP : Email :
g. Nama Akun Media Sosial : 1. Ada, Sebutkan 2. Tidak Ada

4. JENIS KELAMIN : (L/P)

5. NAMA JABATAN PETUGAS KB TINGKAT DESA/KELURAHAN :
* Centang Salah Satu

1. PKB a. Trampil d. Pertama g. Utama

b. Mahir e. Muda
c. Penyelia f. Madya
2. PLKB a. PNS
b. Non PNS

6. SK PENGANGKATAN (PLKB Non PNS) : 1. Ada 2. Tidak Ada

a. SK : Nomor Tanggal
b. Dikeluarkan Oleh : 1. Gubernur 2. Sekda/Bupati/Walikota 3. PD KB
7. NIP :
8. NIK :

9. PENDIDIKAN TERAKHIR : 1. SMA 2. D1 3. D2 4. D3 5. D4/S1 6. S2 7. S3

9. PROGRAM STUDI : 1. Dokter 2. Perawat 3. Bidan 4. Lainnya, ............ (Kode)
10. PANGKAT & GOLONGAN :

11. PELATIHAN : 1. LDU 2. Refreshing 3. Penjenjangan 4. Belum Terlatih

* Dapat dipilih lebih FUNGSIONAL
dari satu

12. PELATIHAN TEKNIS : 1. Pencatatan & Pelaporan 4. KIE 7. Belum Terlatih

* Dapat dipilih lebih dari satu

2. KIP/Konseling 5. Kependudukan 8. Pembangunan Keluarga

3. Advokasi 6. Substansi Lainnya

13. PERLENGKAPAN Tahun Perolehan Tahun Perolehan

: 1. PLKB Kit 4. Android
: 2. KIE Kit 5. Sarana Lainnya
: 3. Sepeda Motor 6. Belum Memiliki

Kode Kualifikasi Pendidikan Bidang Ilmu Sosial atau Kualifikasi Pendidikan Lain Yang Relevan :

a : Ilmu Komunikasi k : Ilmu Pemerintahan

b : Hubungan Masyarakat l : Ilmu Manajemen
c : Manajemen Komunikasi dan Media m : Kebijakan Publik
d : Komunikasi Penyiaran Islam n : Studi Pembangunan (Perencanaan Pembangunan, Wilayah, Kota)
e : Ilmu Kesejahteraan Sosial o : Psikologi Umum
f : Sosiologi p : Kesehatan Masyarakat
g : Antropologi q : Ilmu Keluarga
h : Ilmu Sosiatri r : Pendidikan Anak Usia Dini
i : Kependudukan (Demografi) s : Pendidikan Luar Sekolah
j : Ilmu Administrasi (Niaga, Negara, Publik, Pembangunan, dll) t : Pendidikan Kependudukan dan Lingkungan Hidup
14. KELURAHAN/DESA BINAAN :
* Jika Lebih Dari Satu, Tulis Semua Desanya
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Menyetujui,
KEPALA PD KB Kab/Kota
( ........................................................ )
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,
PKB/PLKB Kecamatan .......................
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