JUDUL

No. Kode :
Terbitan :
KERANGKA No. Revisi :
ACUAN Tgl. Mulai
Berlaku :
PEMERINTAH UPT PUSKESMAS
KAB.BANJARNEGARA Halaman : KALIBENING
Ditetapkan Oleh : Tanda Tangan : Ristiyono, SKM
Kepala UPT Puskesmas Kalibening
................................ NIP. 19631124198501 1 001

A. PENDAHULUAN ( Semua isi ..Arial 12 )

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B. LATAR BELAKANG
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C. TUJUAN
1. Tujuan Umum
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2. Tujuan Khusus
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D. TATA NILAI PROGRAM

Tata Nilai Dalam Pelaksanaan kegiatan : SIP (Santun, Inovatif, Profesional)

E. TATA HUBUNGAN KERJA LINTAS SEKTOR DAN LINTAS PROGRAM

1. Lintas Sektor

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2. Lintas Program
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F. KEGIATAN POKOK DAN RINCIAN KEGIATAN

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G. CARA MELAKSANAKAN KEGIATAN

1. Metode
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2. Teknologi

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H. SASARAN
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I. JADWAL PELAKSANAAN
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J. SUMBER BIAYA
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K. EVALUASI PELAKSANAAN KEGIATAN DAN PELAPORAN

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L. PENCATATAN, PELAPORAN DAN EVALUASI KEGIATAN

Kegiatan Pencatatan, Pelaporan dan Evaluasi kegiatan meliputi :

Penanggung Jawab Pelaksana

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