DINAS KESEHATAN KABUPATEN SUMBAWA BARAT

UPTD PUSKESMAS TALIWANG

JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

LAPORAN KUNJUNGAN
1. Dasar :094/ /PKM-TLW/SPT/ /2019

2. TujuanKunjungan :

3. HasilKunjungan / Rapat :
N TARGET
TANGGAL KEGIATAN CAPAIAN KET
O SASARAN
1
2
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4. Kesimpulan / Saran : …………………………………………………………………………………………

………………………………………………………………………………………..
Taliwang, 2019

Pelapor,

………………………………………………………….

BERITA ACARA SERAH TERIMA LIMBAH MEDIS

 DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

Pada hari ini................. tanggal..............................kami yang bertanda tangan dibawah ini :

Nama :

Jabatan :

Alamat :

Selanjutnya disebut PIHAK PERTAMA

Nama :

Jabatan :

Alamat :

Selanjutnya disebut PIHAK KEDUA

PIHAK PERTAMA menyerahkan limbah kepada PIHAK KEDUA, dan PIHAK KEDUA
menayatakan telah menerima barang dari pihak PERTAMA berupa daftar terlampir :

NO Jenis Limbah Jumlah

Limbah tersebut dalam keadaan terbungkus didalam container sejak penandatanganan berita
acara ini, maka limbah tersebut menjadi tanggung jawab PIHAK KEDUA, pengangkutan dan
pemusnahan sesuai dengan prosedur yang telah disepakati melalui surat perjanjian kerjasama
yang telah ditandatangani bersama.

Demikian berita acara serah terima ini dibuat oleh kedua belah pihak agar dapat dipergunakan
sebagaimana mestinya.

Yang Menerima : Yang Menyerahkan,

PIHAK KEDUA PIHAK PERTAMA

(............. ............ ............) (.............. ..........................)

DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com
 DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

LAPORAN KUNJUNGAN / RAPAT

1. Dasar : / PKM/J/ / 2015

2. Tujuan Kunjungan : Pengantaran POA BOK
3. Hasil Kunjungan / Rapat : .- Pengantaranlaporan POA BOK yang diserahkanlangsungke TIM BOK
DinasKesehatanKabupaten Sumbawa Baratygterdiridari:
1. POA BOK
2. MatrikKegiatan
3. FC. NotulenMinilokBulanan
4. DaftarHadirMinilokBulanan
5. SuratPengantar
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4. Kesimpulan / Saran : ..................................................................................................................
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Jereweh, _____________________ 2015

Pelapor,

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NIP
 DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

LAPORAN KUNJUNGAN / RAPAT

1. Dasar : / PKM/J/ / 2015

2. Tujuan Kunjungan : PengambilanHasilPerifikasidanPengantaran SPU
3. Hasil Kunjungan / Rapat : .- Pengambilan POA HasilPerifikasi yang sudah di sahkankepaladinas
- Pengantaran SPU UntukKegiatanBulanan yang sesuaidenganhasil
POA Perifikasi.
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4. Kesimpulan / Saran :..................................................................................................................
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Jereweh, _____________________ 2015

Pelapor,

....................................................................

NIP
 DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

LAPORAN KUNJUNGAN / RAPAT

1. Dasar : / PKM/J/ / 2015

2. Tujuan Kunjungan : Konsultasi SPJ BOK
3. Hasil Kunjungan / Rapat: .- Diskusidan Tanya Jawabdengan Tim BOK DinasKesehatan
Kabupaten Sumbawa Barat.
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4. Kesimpulan / Saran : SPJ Harusdiserahkanketim BOK DinasKesehatanKabupaten
Sumbawa Barat setiaptanggal 15 setiapbulannya.
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Jereweh, _____________________ 2015

Pelapor,

....................................................................

NIP

7
 DINAS KESEHATAN KABUPATEN SUMBAWA BARAT
UPTD PUSKESMAS TALIWANG
JL. Undru No. 06 Kel.KuangKec.Taliwang ,Kab.Sumbawa Barat ,KodePos .84355
Tlp : 0372 8283130 Email : Smillearea.pkmtaliwang@gmail.com

LAPORAN KUNJUNGAN / RAPAT

1. Dasar : / PKM/J/ / 2015

2. Tujuan Kunjungan : Pengantaran SPJ BOK
3. Hasil Kunjungan / Rapat : .- Laporan SPJ BOK di serahkankepadatim BOK DinasKesehatan
Kabupaten Sumbawa Barat
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4. Kesimpulan / Saran ..................................................................................................................
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Jereweh, _____________________ 2015

Pelapor,

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NIP