JUDUL
No. Dokumen : ……………………….
No. Revisi : ……………………….
KAK
Tanggal Terbit : 02 Januari 2018
Halaman : 1/2
KABUPATEN UPTD
INDRAMAYU PUSKESMAS
dr. H. Rosyid MN,, MMARS BONGAS
NIP. 19690911 201412 1 001
A. PENDAHULUAN
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B. LATAR BELAKANG
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C. TUJUAN
1. Tujuan Umum:
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2. Tujuan Khusus :
a. ………………………………………………………………………
b. ………………………………………………………………………
c. dst
D. KEGIATAN
1. …………………………………………………………………………………………..
2. ………………………………………………………………………………………….
Halaman : 2/2
E. CARA MELAKSANAKAN KEGIATAN
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F. SASARAN
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G. JADWAL PELAKSANAAN
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H. EVALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN
1. ……………………………………………………………………………………………….
2. ………………………………………………………………………………………………
3. ………………………………………………………………………………………………
I. PENCATATAN PELAPORAN DAN EVALUASI KEGIATAN
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PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS BONGAS
Jln. Raya Gebang-Mampang Margamulya Kec.Bongas Kab. Indramayu
e-mail : puskesmasbongas@yahoo.com HP : 085315229191 kode pos 45255
TENTANG
................................................................................................................
.....................................................
Menimbang : a. bahwa.......................;
b. bahwa.......................;
c. bahwa.......................;
d. dst
Mengingat : 1. ……….…….;
2. ……………..;
3. ……………..;
4. dst
MEMUTUSKAN:
Kesatu : .........................................;
Kedua : ..........................................;
Ditetapkan di : Bongas
Pada tanggal : ..............
KEPALA UPTD PUSKESMAS BONGAS,
JUDUL
A. .............................................................................................................
1. .......................................................................................................
2. ........................................................................................................
3. ........................................................................................................
4. ........................................................................................................
5. dsb
B...............................................................................................................
1.............................................................................................................
2. ...........................................................................................................
3. ...........................................................................................................
4. dsb
UPTD
KABUPATEN
PUSKESMAS
INDRAMAYU
dr. H. Rosyid MN, MMARS BONGAS
NIP. 19690911 201412 1 001
1. Pengertian .................................................
5. Prosedur / 1.
Langkah - 2.
Langkah 3. dst
6. Bagan Alir .................................................
7. Hal-hal yang .................................................
perlu
diperhatikan
8. Unit Terkait 1.
2.
3. dsb
9. Rekaman
No Yang dirubah Isi Perubahan Tgl.mulai
historis
diberlakukan
perubahan