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1. ISI DENGAN LENGKAP DAN JELAS MENGGUNAKAN HURUFBALOK
2. BERI LINGKARAN PADA JAWABAN YANGDIPILIH
3. NAMA INSTANSI : MISALNYA POLINDES.WILAYAHPUSKESMAS.ATAU NAMA RS ..
IBI RANTING : RANTING VI BANYUWANGI .
NAMA BIDAN : NICKEN PRAWITASARI, Amd.Keb .
TEMPAT & TANGGAL LAHIR : LUMAJANG, 11 JANUARI 1991 .
ALAMAT RUMAH : DSN.JAGALAN RT/RW 002/002, DS. ROGOJAMPI, .
KEC. ROGOJAMPI, KAB. BANYUWANGI .
NO. TELEPON / HP : 085336035568 .
NO. KTA : PUSAT : 13.20. .. /KTA SEMENTARA : C. BWI-1168
PENDIDIKAN TERAKHIR : DIII KEBIDANAN .
TEMPAT KERJA : RS/ RS SWASTA/ PKM/ PKM PEMBANTU/ POLINDES/ .
POSKESDES/ KLINIK/ RB/ BPM MURNI/ PENDIDIKAN .
STATUS KEPEGAWAIAN : PNS/ PTT/ SWASTA/ BOKER/ MAGANG/ PURNA TUGAS/ .
THL/ TLK .
NAMA INSTANSI : UPTD PUSKESMAS GITIK .
ALAMAT INSTANSI : JL.DIPONEGORO NO.24, GITIK  ROGOJAMPI .
NO. STR/ SIB : P2T/4101/03.01/01/IV/2012 .
STR/ SIB BERLAKU S/D (TGL, BLN, THN) : 11 JANUARI 2017 .
NO. SIKB : 220/ SIKB/ 429.114/ VIII/ 2014 .
SIKB BERLAKU S/D (TGL, BLN, THN) : 11 JANUARI 2017 .
NO. SIPB : _____________________________________________________
SIPB BERLAKU S/D (TGL, BLN, THN) : _____________________________________________________
STATUS BIDAN DELIMA : _____________________________________________________
1. SUDAH LULUS TAHUN : ______________________________________________________
2. BARU DAFTAR : TGL :.-.-201. .
3. CALON BIDAN DELMA BELUM DIVALIDASI : SDH DAPAT PAKET BIDAN DELIMA/ BELUM
4. CALON BIDAN DELIMA SUDAH DIVALIDASI : TGL : ..-.-201.
PELATIHAN YG PERNAH DIIKUT :
a. APN (TGL,BLN,THN,TEMPAT) : 9 S/D 18 SEPTEMBER 2013 DI PUSAT PELATIHAN KLINIK
PRIMER (P2KP) KABUPATEN BANYUWANGI
b. CTU (TGL,BLN,THN,TEMPAT) :
c. LAIN-LAIN (SEBUTKAN) :
1) __________________________________________________________________________________
2) __________________________________________________________________________________
3) __________________________________________________________________________________
4) __________________________________________________________________________________
GOL DARAH : A .
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Formulir

  • 1. 1. ISI DENGAN LENGKAP DAN JELAS MENGGUNAKAN HURUFBALOK 2. BERI LINGKARAN PADA JAWABAN YANGDIPILIH 3. NAMA INSTANSI : MISALNYA POLINDES.WILAYAHPUSKESMAS.ATAU NAMA RS .. IBI RANTING : RANTING VI BANYUWANGI . NAMA BIDAN : NICKEN PRAWITASARI, Amd.Keb . TEMPAT & TANGGAL LAHIR : LUMAJANG, 11 JANUARI 1991 . ALAMAT RUMAH : DSN.JAGALAN RT/RW 002/002, DS. ROGOJAMPI, . KEC. ROGOJAMPI, KAB. BANYUWANGI . NO. TELEPON / HP : 085336035568 . NO. KTA : PUSAT : 13.20. .. /KTA SEMENTARA : C. BWI-1168 PENDIDIKAN TERAKHIR : DIII KEBIDANAN . TEMPAT KERJA : RS/ RS SWASTA/ PKM/ PKM PEMBANTU/ POLINDES/ . POSKESDES/ KLINIK/ RB/ BPM MURNI/ PENDIDIKAN . STATUS KEPEGAWAIAN : PNS/ PTT/ SWASTA/ BOKER/ MAGANG/ PURNA TUGAS/ . THL/ TLK . NAMA INSTANSI : UPTD PUSKESMAS GITIK . ALAMAT INSTANSI : JL.DIPONEGORO NO.24, GITIK ROGOJAMPI . NO. STR/ SIB : P2T/4101/03.01/01/IV/2012 . STR/ SIB BERLAKU S/D (TGL, BLN, THN) : 11 JANUARI 2017 . NO. SIKB : 220/ SIKB/ 429.114/ VIII/ 2014 . SIKB BERLAKU S/D (TGL, BLN, THN) : 11 JANUARI 2017 . NO. SIPB : _____________________________________________________ SIPB BERLAKU S/D (TGL, BLN, THN) : _____________________________________________________ STATUS BIDAN DELIMA : _____________________________________________________ 1. SUDAH LULUS TAHUN : ______________________________________________________ 2. BARU DAFTAR : TGL :.-.-201. . 3. CALON BIDAN DELMA BELUM DIVALIDASI : SDH DAPAT PAKET BIDAN DELIMA/ BELUM 4. CALON BIDAN DELIMA SUDAH DIVALIDASI : TGL : ..-.-201. PELATIHAN YG PERNAH DIIKUT : a. APN (TGL,BLN,THN,TEMPAT) : 9 S/D 18 SEPTEMBER 2013 DI PUSAT PELATIHAN KLINIK PRIMER (P2KP) KABUPATEN BANYUWANGI b. CTU (TGL,BLN,THN,TEMPAT) : c. LAIN-LAIN (SEBUTKAN) : 1) __________________________________________________________________________________ 2) __________________________________________________________________________________ 3) __________________________________________________________________________________ 4) __________________________________________________________________________________ GOL DARAH : A .