PEMERINTAH KABUPATEN INDRAMAYU

DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec. Karangampel Kab. Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / 292.1 / Puskesmas

Dasar :
Surat dari Dinas Kesehatan kab.Indramayu Nomor : 005/ 1015. Kesmas tanggal
15 Maret 2023 tentang Bimbingan teknis pelayanan skrining hipotiroid kongenital pada bayi
baru lahir, maka dengan ini :

MEMERINTAHKAN

Kepada
NO NAMA NIP JABATAN PANGKAT/GOL

1 Jubaedah,S.S.T,Bdn 197401061993022001 Bidan IV a

2 Lely Robiah,S.Tr.keb ‘- Bidan ‘-

Untuk : Mengirim berkas pembukaan rekening dan laporan keuangan

Tanggal : 20 Maret 2023
Tujuan : Dinas Kesehatan
Jl. MT Haryono No. 9 Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 20 Maret 2023
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

Penata Muda TK I / III b
NIP.199104052019032015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : Senin/ 20 Maret 2023

Tempat : Aula Kopsuka
Keperluan : Bimbingan teknis pelayanan skrining hipotiroid kongenital pada bayi
baru lahir
Hasil : ....................................................................................................................
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Indramayu, 20 Maret 2023

Pelaksana kegiatan

Jubaedah,S.S.T,Bdn

Lely Robiah,S.Tr.keb
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / 291.1 / Puskesmas

Dasar :
Surat dari Dinas Kesehatan Kab. Indramayu Nomor 005/ 914/ P2P Tanggal 8
Maret 2023 tentang Pertemuan Program Gangguan Indera Fungsional bagi
petugas GIF tahun 2023, maka dengan ini :

MEMERINTAHKAN

0Kepada

Nama : Diyah Pitalokasi,Amd.keb

NIP :-
Jabatan : Bidan
Pangkat / Gol. : -

Untuk : Mengikuti Pertemuan Program Gangguan Indera Fungsional P

Tanggal : 21 Maret 2023
Tujuan : Aula Dinas Kesehatan

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 21 Maret 2023
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

Penata Muda TK I / III b
NIP.199104052019032015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : Rabu / 22 Desember 2021

Tempat : RSUD Kab. Indramayu
Keperluan : Mengirim limbah medis B3
Hasil : .....................................................................................................................
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Indramayu,
Pelaksana kegiatan

Ichwanti, SKM
NIP. 19810408 200801 2 005
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec. Karangampel Kab. Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Peraturan Mentri Kesehatan Republik Indonesia No. 12 Tahun 2021 tentang petunjuk
teknis penggunaan dana alokasi khusus non fisik bidang kesehatan, maka dengan ini :

MEMERINTAHKAN

Kepada

Nama : Iskandar, S.Kep, Ners

NIP : 197209242001121001
Jabatan : Perawat ahli muda
Pangkat / Gol. : Penata Tk I / III d

Untuk : Mengambil data aset tetap puskesmas dari Badan Keuangan Daerah
(BKD)
Tanggal : 02 Maret 2023
Tujuan : Badan Keuangan Daerah (BKD) Kab. Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 2 Februari 2023
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

NIP.199104052019032015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec. Karangampel Kab. Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : /
Tempat : Dinas Kesehatan Indramayu
Keperluan : Konsultasi laporan buku kas umum dan mengirim revisi SPJ BOK
Hasil : ...................................................................................................................
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Indramayu,
Pelaksana kegiatan

Mahartika retno febri. A, SE

NIP. -
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Peraturan Bupati Indramayu No. 2 Tahun 2021 tentang Pengelolaan Keuangan Badan
layanan Umum Daerah Pusat Kesehatan Masyarakat, maka dengan ini :

MEMERINTAHKAN

Kepada

Nama : Iskandar, S.Kep, Ners

NIP : 197209242001121001
Jabatan : Perawat
Pangkat / Gol. : Penata Tk I / III d

Untuk : Mengambil permintaan obat program Kesehatan jiwa

Tanggal : 17 Maret 2023
Tujuan : Dinas Kesehatan Kab. Indramayu
Jl. MT Haryono No. 9 Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 16 Maret 2023
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

Penata Muda TK I / III b
NIP.199104052019032015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : Jumat / 17 Maret 2023

Tempat : Dinas Kesehatan Kab. Indramayu
Keperluan : Pengambilan obat program Kesehatan jiwa
Hasil : ...................................................................................................................
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Indramayu, 17 Maret 2023

Pelaksana kegiatan

Iskandar, S.Kep, Ners

NIP. 197209242001121001
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec. Karangampel Kab. Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Peraturan Mentri Kesehatan Republik Indonesia No. 12 Tahun 2021 tentang petunjuk
teknis penggunaan dana alokasi khusus non fisik bidang kesehatan, maka dengan ini :

MEMERINTAHKAN

Kepada
NO NAMA NIP JABATAN PANGKAT/GOL

1 Iskandar, S.Kep, Ners 19720924 200112 1 001 Perawat III d

2 Mahartika Retno. F.A, SE ‘- Pendamping ‘-

keuangan

Untuk : Mengirimkan laporan keuangan BLUD tahun 2022

Tanggal : 01 Februari 2023
Tujuan : Inspektorat kab. Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 01 Februari 2023
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

NIP. 19910405 201903 2 015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : Kamis / 15 Desember 2022

Tempat : Hotel Grand Trisula Indramayu
Keperluan : Mengikuti evaluasi pelimpahan UP dan desk pengembalian pelimpahan
UP tahun anggaran 2022
Hasil : .....................................................................................................................
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Indramayu, 15 Desember 2022
Pelaksana kegiatan

Iskandar, S.Kep, Ners

NIP.197209242001121001

Mahartika Retno Febri. A, SE

 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec. Karangampel Kab. Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Surat dari Dinas Kesehatan Kab. Indramayu Nomor : 856 / 016.P2P tanggal 27 Juli
2020. Perihal distribusi logistik covid 19, suplemen dan vitamin, maka dengan ini :

MEMERINTAHKAN

Kepada
NO NAMA NIP JABATAN PANGKAT/GOL

1 Iskandar, S.Kep, Ners 19720924 200112 1 001 Perawat III c

2 Mahartika Retno Febri. A, SE - Operator -

Untuk : Mengambil logistik covid 19, suplemen dan vitamin

Tanggal : 27 Juli 2020
Tujuan : Dinas Kesehatan Kab. Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 27 Juli 2020
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. UDIN RUSAD NURDIN, MH.Kes

Penata Tk I / III d
NIP.19651005 200701 1 021
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal : Kamis / 1 Oktober 2020

Tempat : Dinas Kesehatan Kab. Indramayu
Keperluan : Konsultasi keuangan dan kegiatan BOK
Hasil : ...................................................................................................................
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Indramayu, 1 Oktober 2020

Pelaksana kegiatan
Nama Tanda tangan

Iskandar, S.Kep, Ners

Mahartika Retno Febri. A, SE

 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Peraturan Mentri Kesehatan Republik Indonesia No. 12 Tahun 2021 tentang petunjuk
teknis penggunaan dana alokasi khusus non fisik bidang kesehatan, maka dengan ini :

MEMERINTAHKAN

Kepada

Nama : Mahartika Retno Febri. A, SE

NIP :-
Jabatan : Pendamping keuangan
Pangkat / Gol. : -

Untuk : Konsultasi dan mengirimkan spj tenaga pendamping BOK

Tanggal :
Tujuan : Dinas Kesehatan Kabupaten Indramayu
Jl. MT Haryono No 9 Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal :
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Udin Rusad Nurdin MH.Kes

Pembina / IV a
NIP.19651005 200701 1 021
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL PERJALANAN DINAS

Hari / Tanggal :
Tempat : Dinas Kesehatan Kabupaten Indramayu
Keperluan : Konsultasi dan mengirimkan spj tenaga pendamping BOK
Hasil : ...................................................................................................................
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Indramayu,
Pelaksana kegiatan

Mahartika Retno Febri. A, SE

NIP. -
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Desa Kaplongan Lor No 3 Kec.Karangampel Kab.Indramayu 45283
telp (0234) 7135351 Email:puskesmaskaplongan@yahoo.co.id

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Peraturan Bupati Kabupaten Indramayu No. 07 tahun 2020 tentang Pedoman Pelaksanaan
Bantuan Operasional Kesehatan (BOK) di Kabupaten Indramayu,
maka dengan ini :

MEMERINTAHKAN

Kepada :
NO NAMA NIP JABATAN PANGKAT/GOL

1 Iskandar, S.Kep, Ners 19720924 200112 1 001 Perawat III c

2 Mahartika Retno Febri. A, SE - Operator -

Untuk : Konsultasi keuangan dan kegiatan BOK

Tanggal : 17 Juli 2020
Tujuan : Dinas Kesehatan Kab. Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 16 Juli 2020
KEPALA UPTD PUSKESMAS
KAPLONGAN

Dr. Udin Rusad Nurdin MH.Kes

Penata Tk I / III d
NIP.19651005 200701 1 021
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jln. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Surat dari Dinas Kesehatan Kab. Indramayu Nomor : 410 / / SDK tanggal 05 April
2022. Perihal Undangan pengelolaan data terpadu kesejahteraan social (DTKS), maka
dengan ini :

MEMERINTAHKAN

Kepada

Nama : Tien Suwartini, S.Kep, Ners

NIP : 19760828 199702 2 001
Jabatan : Kasub Bag TU
Pangkat / Gol. : Penata Tk I / III d

Untuk : Pertemuan pengelolaan data terpadu kesejahteraan sosial

Tanggal : 06 April 2022
Tujuan : Aula Lantai 2 – Dinas Kesehatan
Jl. MT Haryono No. 9 Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 05 April 2022
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. Gisela Afriyanti

Penata Muda Tk I / III b
NIP.19910405 201903 2 015
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jln. Raya Desa Kaplongan Lor Kec.Karangampel Kab.Indramayu 45283

LAPORAN HASIL KUNJUNGAN

Hari / Tanggal : Senin / 8 November 2021

Tempat : Dinas Kesehatan Kab. Indramayu
Keperluan : Konsultasi RBA BLUD, RKA BOK dan BOP TA 2022
Hasil : ...................................................................................................................
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Indramayu, 8 November 2021

Pelaksana kegiatan

Tien Suwartini, S.Kep, Ners

NIP. 19720924 200112 1 001
 PEMERINTAH KABUPATEN INDRAMAYU
DINAS KESEHATAN
UPTD PUSKESMAS KAPLONGAN
Jl. Desa Kaplongan Lor No 3 Kec. Karangampel Kab. Indramayu 45283

SURAT PERINTAH TUGAS

Nomor : 090 / / Puskesmas

Dasar :
Surat dari Dinas Kesehatan Kab. Indramayu Nomor : / / tanggal 25
Januari 2021. Perihal Undangan Rekonsiliasi data pendapatan dan belanja BLUD Tahun
2020, maka dengan ini :

MEMERINTAHKAN

Kepada
NO NAMA NIP JABATAN PANGKAT/GOL

1 Iskandar, S.Kep, Ners 19720924 200112 1 001 Perawat III c

2 Ayat Nurhayati, S.Kep, Ners 197712182006042013 Perawat III c

3 Ichwanti, SKM 198104082008012005 Sanitarian III b

Untuk : Mengikuti Rekonsiliasi data pendapatan dan belanja BLUD tahun 2020
Tanggal : 28 Januari 2021
Tujuan : Dinas Kesehatan Kab. Indramayu
Jl MT. Haryono no 9, Indramayu

Ditetapkan di : Puskesmas Kaplongan

Pada tanggal : 27 Januari 2021
KEPALA UPTD PUSKESMAS
KAPLONGAN

dr. UDIN RUSAD NURDIN, MH.Kes

Pembina / IV a
NIP.19651005 200701 1 021