KODE : FORM-PoltekkesTjk/C.002/..........

POLTEKKES TANJUNGKARANG KEMENKES RI

TGL : Januari 2015
Formulir REVISI : 0
Berita Acara Praktik Klinik / Lapangan HALAMAN : 1 dari 1 Halaman

BERITA ACARA PRAKTIK KLINIK / LAPANGAN

TAHUN AKADEMIK ................./ ..................

Mata Kuliah : .............................................................................. Ruangan : ................................................................

Kode / SKS : .............................................................................. Hari / Jam : ................................................................
Pj. Mata Kuliah : .............................................................................. Kelas : ................................................................
Dosen Pembimbing : .............................................................................. Semester / Prodi : …………………./ Profesi Ners

Paraf Ket
Jml
Materi Bimbingan Wakil Dose CI / (luring/mandiri/d
Mhs g CI)
Mhs n Karu

Mengetahui …………………………………….. 20…………..

Diklat/Puskesmas/Panti/Ruangan) ………………………………… Ketua Program Studi Profesi Ners
Kepala,

______________________________________________ Dwi Agustanti, S.Kep., M.Kep., Sp.Kom.

NIP…………………………………………………….. NIP 197108111994022001
 KODE : Format/PKTjk/J.Kep/03.2/1/2015
POLITEKNIK KESEHATAN TANJUNGKARANG KEMENKES RI TGL : Maret 2015
Formulir REVISI :
Daftar Hadir Bimbingan Klinik / Lapangan HALAMAN : 1 dari 1 Halaman

DAFTAR HADIR MAHASISWA

BIMBINGAN PRAKTIK KLINIK / LAPANGAN
Mata Kuliah : ................................................................................................................. Ruangan : ...................................................................................................................
Kode Mata Kuliah / Sks : ................................................................................................................. Kelas : ...................................................................................................................
Pj. Mata Kuliah : ................................................................................................................. Semester / Prodi : ............ / Profesi Ners
Dosen Pembimbing : ................................................................................................................. Kelompok : ...................................................................................................................

Tanggal
No Nama Mahasiswa

10

11

12

Paraf Dosen Pembimbing

Mengetahui …………………………………….. 20…………..

Diklat/Puskesmas/Panti/Ruangan) ………………………………… Ketua Program Studi Profesi Ners
Kepala,

______________________________________________ Dwi Agustanti, S.Kep., M.Kep., Sp.Kom.

NIP…………………………………………………….. NIP 197108111994022001