Yang bertanda tangan di bawah ini dokter UPTD Puskesmas Perawatan Sepinggan Baru Kota
Balikpapan, menerangkan bahwa :
Nama : ...............................................................................................................................................
Umur : ...............................................................................................................................................
Jenis Kelamin : ...............................................................................................................................................
Pekerjaan : ...............................................................................................................................................
Alamat : ...............................................................................................................................................
..................................................................................................................................................
Setelah diperiksa kesehatan matanya pada tanggal tersebut dan kedapatan : TIDAK BUTA WARNA
Surat keterangan Buta Warna dipergunakan untuk :............................................................................................
Balikpapan, .............................2023