1. Dasar Penugasan : Surat tugas Nomor : ............../ST/BOK/UPT.PKMBBT/ /2021
2. Nama Petugas/TIM : 1. ........................................... 2. ........................................... 3. Tujuan Perjalanan : ............................................ 4. Tanggal Perjalanan : ............................................ 5. Maksud Perjalanan : ............................................ 6. Pejabat Yang Ditemui : ............................................
7. Hasil Kunjungan, Antara Lain :
a. Proses Pelaksanan : ............................................................................................................................. ............................................................................................................................ ............................................................................................................................. …........................................................................................................................ ............................................................................................................................ ............................................................................................................................ b. Hasil : ............................................................................................................................. ............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. c. Saran Perbaikan/Kesimpulan : .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................. .............................................................................................................................
Mengetahui, Petugas Tanda Tangan
PLT Pimpinan UPT Puskesmas Babatan 1. ..................................