PEMERINTAH KABUPATEN PASAMAN

DINAS KESEHATAN
RUMAH SAKIT KELAS D PASAMAN
Jln. Lintas Sumatera Km.8, Jrg. Selamat Utara-Nagari Sitombol, Kec. Pdg.Gelugur, KodePos. 26352
E-mail : rspasaman@gmail.com

PROFIL TENAGA KEPERAWATAN

DATA BASE
1. Nama Lengkap :............................................................................................................
2. Nomor KTP :............................................................................................................
3. Tempat Lahir : ...........................................................................................................
4. Tanggal Lahir : ...........................................................................................................
5. Jenis Kelamin : ...........................................................................................................
6. Agama : ...........................................................................................................
7. Status Perkawinan : ...........................................................................................................
8. Alamat Rumah : ...........................................................................................................
9. Nomor Hp : ...........................................................................................................
10. Alamat Email : ...........................................................................................................

DATA IDENTITAS PROFESI

A. DATA PENDIDIKAN
1. Ijazah Terakhir : ...........................................................................................................
2. Nomor Ijazah : ...........................................................................................................
3. Tahun Ijazah : ...........................................................................................................
4. Institusi Pendidikan : ...........................................................................................................
B. DATA PROFESI
1. No. KTA Profesi : ...........................................................................................................
2. Masa Berlaku : ...........................................................................................................
3. No. STR : ...........................................................................................................
4. Masa Berlaku : ...........................................................................................................
5. No. SIK : ...........................................................................................................