PEMERINTAH KAUPATEN OGAN KOMERING ULU TIMUR

INSPEKTORAT DAERAH
Jl. LINTAS SUMATERA KM.7 KOTA BARU SELATAN  0735.481873
MARTAPURA

DAFTAR ISIAN PUSKESMAS

I. Puskesmas : ..................................................................................................
Lokasi : ..................................................................................................

II. Data Pegawai

A. Pimpinan
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

B. Staf Pelaksana
1. Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

2. Nama/ NIP :.......................................NIP........................................

Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

3. Nama/ NIP :.......................................NIP........................................

Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

4. Nama/ NIP :.......................................NIP........................................

Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

5. Nama/ NIP :.......................................NIP........................................

Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

Hal 1
 6. Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

7. Nama/ NIP :.......................................NIP........................................

Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

C. Klasifikasi Kepegawaian
A. Jumlah Pegawai
Jumlah Pegawai Definitif : ...........................orang
Jumlah Pegawai Honorer : ...........................orang

B. Klasifikasi Kepangkatan
 Golongan IV : ...........................orang
 Golongan III : ...........................orang
 Golongan II : ...........................orang
 Golongan I : ...........................orang
Jumlah : ...........................orang

C. Klasifikasi Pendidikan
 Sarjana (S2) : ...........................orang
 Sarjana (S1) : ...........................orang
 Diploma III : ...........................orang
 Diploma II : ...........................orang
 Diploma I : ...........................orang
 SMU : ...........................orang
 SMP : ...........................orang
 SD : orang
Jumlah : ...........................orang

D. BIDANG APARATUR

1. Apakah sudah dibuat DUK setiap tahun?..............................................................

( lampiran DUK tahun terakhir )

2. Adakah Jabatan Struktural yang lowong atau belum terisi?Sebutkan...................

...............................................................................................................................
( Lampiran Struktur Organisasi )

Hal 2
3. Adakah Pejabatan yang ditunjuk sebagai PLT sedangkan ada PNS yang
pangkatnya telah memenuhi persyaratan untuk diangkat dalam Jabatan
tersebut? ( apa alasan & komentar ).....................................................................
...............................................................................................................................

4. Apakah semua PNS yang menduduki Jabatan Struktural sudah mengikuti

kursus / penjenjangan, jika belum siapa nama PNS tersebut dan apa
alasannya?............................................................................................................
...............................................................................................................................

5. Adakah pejabat yang pangkatnya lebih rendah membawahi secara langsung

PNS yang pangkatnya lebih tinggi, jika ada alasannya?.......................................
................................................................................................................................

6. Adakah Pejabat yang menduduki jabatan rangkap?..............................................

................................................................................................................................

7. Adakah PNS yang tidak aktif menjalankan tugas, bila ada apakah sudah diberi
peringatan? Jika belum apa alasannya!................................................................
................................................................................................................................

8. Adakah PNS melanggar ketentuan jam kerja apel pagi siang, jika ada apakah
sudah diberi peringatan (Lampirkan Buktinya dan jika belum apa
alasannya)?...........................................................................................................
................................................................................................................................

9. Adakah penyampaian rekab absen (daftar hadir) disampaikan kepada Bupati

OKU Timur Cq. Bagian Ortala Pemda OKU TIMUR (Lampirkan laporan
terakhir)!..................................................................................................................
...............................................................................................................................

10. Apa dasar pembentukan satuan kerja

(lampirkan)?............................................................................................................
...............................................................................................................................

11. Apakah kegiatan satuan kerja!..............................................................................

................................................................................................................................

12. Adakah PNS yang menduduki Jabatan Struktural lebih dari 5 tahun, bila ada
sebutkan apa alasannya! .................................................................................
..........................................................................................................................

Hal 3
III. Sub Keuangan
Bendahara JKN
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................
Sumber Dana : 1.............................................................................
2.............................................................................
3.............................................................................
 Jumlah dana yang Dikelola : Rp .................................
 Jumlah dana yang telah diterima : Rp ................................
 Jumlah dana yang belum diterima : Rp ................................
 Jumlah dana yang telah dipertanggungjawabkan : Rp ................................
 Jumlah dana yang belum dipertanggungjawabkan : Rp ................................

Bendahara BOK
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................
Sumber Dana : 1.............................................................................
2.............................................................................
3.............................................................................
 Jumlah dana yang Dikelola : Rp .................................
 Jumlah dana yang telah diterima : Rp ................................
 Jumlah dana yang belum diterima : Rp ................................
 Jumlah dana yang telah dipertanggungjawabkan : Rp ................................
 Jumlah dana yang belum dipertanggungjawabkan : Rp ................................

Bendahara Rutin/Operasional
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................
Sumber Dana : 1.............................................................................
2.............................................................................
3.............................................................................
 Jumlah dana yang Dikelola : Rp .................................
 Jumlah dana yang telah diterima : Rp ................................
 Jumlah dana yang belum diterima : Rp ................................
 Jumlah dana yang telah dipertanggungjawabkan : Rp ................................
 Jumlah dana yang belum dipertanggungjawabkan : Rp ................................

Hal 4
IV. Sub Kekayaan
Penyimpan/ Pengurus Barang
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT :......................................................................................

Data tanah dan bangunan

Luas tanah :..........................M²
No sertifikat/ Girik :..........................
Tanggal :..........................
Luas Bangunan :..........................M²
Rincian ruangan :
a. : M², Kondisi......
b. : ........................M², Kondisi............................
c. : M², Kondisi......
d. : M², Kondisi......
Data Peralatan dan Perlengkapan
a. : buah, Kondisi. .
b. : ........................buah, Kondisi...........................
c. : buah, Kondisi. .
d. : buah, Kondisi. .
Kendaraan roda dua
a. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................
b. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................
c. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................
d. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................

Hal 5
 Kendaraan roda empat
a. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................
b. Merk/ Type : .........................................................
No. Mesin : .........................................................
No. Rangka : .........................................................
No. Polisi : .........................................................
Pemegang/ Penanggung jawab : .........................................................
Buku Inventaris Kekayaan : .........................................................
KIR dan DIR : .........................................................
Laporan Inventaris Kekayaan : .........................................................

V. Operasional Pelayanan
1. Penanggung jawab gudang obat
Nama/ NIP :.......................................NIP........................................
Pangkat/ Gol :......................................................................................
SK Pengangkatan : No. SK.........................................Tgl...........................
TMT .......................................................................................:

2. Mekanisme Penggunaan dan Distribusi obat-obatan (uraikan)

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Hal 6
3. Jenis dan jumlah obat yang telah diterima sampai dengan bulan ini
(sebutkan):
a. Jumlah :...................................
b. Jumlah :...................................
c. Jumlah :...................................
d. Jumlah :...................................
e. Jumlah :...................................
f. Jumlah :...................................

4. Jenis dan jumlah obat yang telah digunakan sampai dengan bulan ini
(sebutkan):
a. Jumlah :...................................
b. Jumlah :...................................
c. Jumlah :...................................
d. Jumlah :...................................
e. Jumlah :...................................
f. Jumlah :...................................

5. Jumlah obat yang tidak disediakan oleh pemerintah, bagaimana cara

mengatasinya dan berapa biaya yang telah dikeluarkan oleh pasien.
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6. Jenis penyakit yang tidak dapat ditangani dan berapa orang yang telah
dirujuk ke RSUD sampai dengan bulan ini.
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7. Masalah atau kesulitan yang dihadapi dalam pemberian pelayanan.
Hal 7
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VI. Hasil Pemeriksaan tanggal.........................................................

.............., ............................... 2023

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Hal 8