DINAS KESEHATAN
UPTD PUSKESMAS RANAP UJUNGJAYA
Jl Rd. Ali Sadikin KM 05 No 02 Ujungjaya-Sumedang Kode Pos 45383
TELP (0233) 8667264 Email : puskesmasujungjaya@yahoo.co.id
SURAT TUGAS
No : 800/ / ST-BOK/ PUSK UJ /II/ 2022
Tanggal : 12 Februari 2022
Udus Kusnadi,SKM
NIP.19640703198409 1 001
PEMERINTAH DAERAH KABUPATEN SUMEDANG
DINAS KESEHATAN
UPTD PUSKESMAS RANAP UJUNGJAYA
Jl Rd. Ali Sadikin KM 05 No 02 Ujungjaya-Sumedang Kode Pos 45383
TELP (0233) 8667264 Email : puskesmasujungjaya@yahoo.co.id
Lembar Ke :1
Kode No. :-
Nomor : 800/ / PUSK UJ/ II/ 2022
Dikeluarkan di : Sumedang
Pada Tanggal : 12 Februari 2022
Kuasa Pengguna Anggaran
Udus Kusnadi,SKM
NIP 19640703198409 1 001
I. Berangkat dari : Puskesmas Ujungjaya
(Tempat kedudukan)
Ke : Desa Cibuluh
Udus Kusnadi,SKM
NIP 19640703198409 1 001
II. Tiba di : Desa Cibuluh Berangkat dari : Desa Cibuluh
( ............................................ ) ( ............................................ )
NIP NIP
III. Tiba di : - Berangkat dari : -
( ............................................ ) ( ............................................ )
NIP NIP
IV. Tiba di : - Berangkat dari : -
( ............................................ ) ( ............................................ )
NIP NIP
V. Tiba di : Puskesmas ujungjaya Telah diperiksa dengan keterangan bahwa
perjalanan tersebut atas perintahnya dan semata-mata untuk kepentigan
(Tempat Kedudukan)
jabatan dalam waktu yang
Pada Tanggal : 14 Februari 2022 sesingkat-singkatnya.
PA/KPA yang menerbitkan SPD, Pegawai yang melakukan perjalanan dinas, para pejabat yang mensyahkan tanggal berangkat/tiba serta bendahara
pengeluaran bertanggung jawab berdasarkan peraturan-peraturan Keuangan Negara apabila Negara menderita rugi akibat kesalahan, kelalaian dan
kealpaan.
LAPORAN KEGIATAN
Nama Kegiatan :
Nama Petugas :
Jabatan :
Lokasi :
Tanggal :
URAIAN KEGIATAN
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Yang Melaksanakan Tugas
NIP/NRPTT.