Yang bertanda tangan dibawah ini, menerangkan bahwa : Yang bertanda tangan dibawah ini, menerangkan bahwa :
Nama : ............................................................................................. Nama : .............................................................................................
Umur : ............................................................................................. Umur : ............................................................................................. Pekerjaan : ............................................................................................. Pekerjaan : ............................................................................................. Alamat : ............................................................................................. Alamat : .............................................................................................
Telah hamil ........................... Minggu, Telah hamil ........................... Minggu,
Partus / Melahirkan diperkirakan tanggal ........................................., 20........ Partus / Melahirkan diperkirakan tanggal ........................................., 20........ Mulai istirahat / Cuti tanggal ................................... s/d ................................. Mulai istirahat / Cuti tanggal ................................... s/d ................................. Keterangan USG : Keterangan USG : ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ ............................................................ Demikian, harap yang berkepentingan maklum adanya, Terimakasih. Demikian, harap yang berkepentingan maklum adanya, Terimakasih.