201Format k.1 Aplikasi Kredensialing Perawat

CONTOH RS…………………………..

APLIKASI KREDENSIALING PERAWAT

A. IDENTITAS I DENTITAS PERAW PER AWA AT Nama Pemohon : ........................ ..................................... ......................... .......................... .......................... ........................ ........................ ............ NIK : ........................ ..................................... ......................... .......................... .......................... ........................ ........................ ............ TanggalLahir : .........../........../........... ( tanggal/bulan/tahun) tanggal/bulan/tahun )  Alamat : .................... ................................ ......................... .......................... ......................... ......................... ......................... ................ .... ......................... ..................................... ......................... .......................... ......................... ......................... ........................ ........... Telepon : ......................................... HP : .............................................. Email : .......................... ....................................... ......................... ........................ .......................... .......................... ...................... ..........

B. STATUS REGISTRASI Nomor Registrasi/ No.STR : ......................... ...................................... ......................... .......................... .......................... .............. .. Nomor Ijaah : ......................... ..................................... ......................... .......................... ......................... ............... ... Nama Instit!si Pen"i"i#an : ......................... ..................................... ......................... ......................... ........................ ................ .... Tanggal Tanggal L!l!s : ......................... ..................................... .......................... .......................... ........................ ............... ... K!ali$i#asi Pen"i"i#an : %iploma/Ners/ Spesialis.................................. Spesialis......................................... .......

(coret yang

tidakperlu) Penjenjangan Karir : PK & / I / II / III / I' / '

( coret yang tidakperlu)

Nomor serti$i#at #ompetensi : ....................... ..................................... .......................... ......................... ......................... ................ .... asa erla#! sampai : ........./........../.... ........./........../........... ....... (tanggal /bulan/ tahun)

C. STATUS KREDENSIALING YANG DIUSULKAN  A*al Kenai#an ting#at Pem!lihanKe*enangan ......................... ..................................... .......................... ................

(Berikancek list padasalahsatukotak) padasalahsatukotak)

CONTOH RS…………………………..

D. PRASYARAT KREDENSIALING a. Apa#ah an"a pernah "ila#!#an #re"ensialing seel!mn+a, -i#a a t!lis#an #apan "ila#!#ann+a #re"ensialing tera#hir. a

Ti"a#

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  ...........................................................................................................................  . Apa#ah an"a memili#i s!rat pen!gasan #linis +ang menjelas#an #e*enangan #linis an"a, -i#a a t!lis#an tanggal pen!gasan #linis "an nomor s!rat pen!gasan #lini#. a

Ti"a#

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 0. Apa#ah #e*enangan #linis an"a pernah : •

%i#!rangi a

•

%i0a!t

a

Ti"a# Ti"a#

-i#aa t!lis#an #apan hal terse!t terja"i.   ............................................................................................................................  

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 ". Apa#ah an"a pernah terliat "alam persi"angan per"ata ata!p!n pi"ana ter#ait #e*enangan #linis +ang an"a mili#i, -i#a a t!lis#an #apan hal terse!t terja"i. a

Ti"a#

 

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CONTOH RS…………………………..

e. T!lis#an program pengemangan pro$essional er#elanj!tan (1P%) agi pera*at +ang an"a i#!ti "alam 2 tah!n tera#hir 

Tahun

Bukti

Institusi

 Jenis

Kegiatan

(NomorSertifkat/Surat

Penyelenggara

Kegiatan

Tugas/SK )

Kegiatan

$. T!lis#an Ke*enangan #linis +ang "i!s!l#an eserta  !#ti3!#ti pen"!#!ng (ses!ai !#! p!tih) N

Kewenangan Kln!

B"#$ Pen%"#"mg

Ke$erangan

o

E. PERNYATAAN Sa+a men+ata#an ah*a segala hal +ang tert!lis "i "alam "o#!men ini a"alah 4enar a"an+a. Apaila "i #em!"ian hari ter!#ti a"a hal +ang ti"a# enar ma#a Sa+a erse"ia menangg!ng segala #onse#!ensi ses!ai "engan at!ran h!#!m ang erla#!. Tan"aTangan : ................................................................ Nama-elas : ................................................................. (Tulisdenganhurufcetak) Tanggal : ........./........../.......... (Tanggal/Bulan/Tahun)