FORMULIR

PENENTUAN JUDUL KARYA TULIS ILMIAH

Nama Mahasiswa: FAHRAN ARRAHIM

NIM : P031914401012
Judul KTI yang diusulkan berdasarkan prioritas:

No Bidang/departemen Judul
1

Usulan nama pembimbing:

1. R. Sakhnan, SKM, M.Kes
2. Idayanti, S.Pd., M.Kes

Hari/Tanggal Pengumpulan....................................................................................
Pukul :..................................................................................................................
Judul KTI yang disetujui:.........................................................................................

Pekanbaru , ....................2022
Mengetahui Kaprodi Koordinator MK KTI
Idayanti, S.PD., M.Kes Ns. Nia Khusniyati M., M.Kep

(..........................................................) (..........................................................)
NIP. 196910221994032002 NIP. 198903232019022001
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KESEDIAAN PEMBIMBING

Yang bertanda tangan di bawah ini : R. Sakhnan, SKM, M.Kes

1. Nama : R. Sakhnan, SKM, M.Kes

2. NIP : .......................................................................................
3. Pangkat/golongan : .......................................................................................
4. Jabatan : .......................................................................................
5. Asal institusi : .......................................................................................
6. Pendidikan terakhir : .......................................................................................
7. Kontak person
a) Alamat rumah : .......................................................................................
b) Telp/Hp : .......................................................................................
c) Alamat kantor : .......................................................................................
d) Telp kantor : .......................................................................................

Menyatakan (bersedia/tidak bersedia*) menjadi pembimbing bagi mahasiswa:

Nama : Fahran Arrahim
NIM : P031914401012
Dengan Judul : .....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................
.....................................................................................................

*) coret yang tidak dipilih

Pekanbaru, ………………2022

(R. Sakhnan, SKM, M.Kes)

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Nama Mahasiswa : Fahran Arrahim

NIM : P03194401012
Nama Pembimbing : R. Sakhnan, SKM, M.Kes

TANDA
NO TANGGAL MATERI BIMBINGAN SARAN
TANGAN