LAPORAN LAPORA N HARIAN H ARIAN KEGIATAN PELAYANAN PELAYANAN KEPERA KEPER AWATAN ATAN JABATAN FUNGSIONAL PERAWAT AHLI
N A M A N I P . PANGK ANGKA AT / GOLON OLONGA GAN N RUAN RUANG G JABATAN
: : : :
NO
TANGGAL 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
BUTIR KEGIATAN
BULAN UNIT UNIT ORGA ORGANI NISA SASI SI PROPINSI JML
: : : A.K.
I PENDIDIKAN
60 2 1
A.1. Me!"#"$ e&"' / ()"*"+ S1 Ke# B.e. Me!"#"$," STTPL- 81160 )" . Me!"#"$," STTPL- 3080 )"
II PELAYANAN KEPERAWATAN
0-007 0-005 0-002
A.1.". Me&",""," ",e# (!((! 3.1. R," !("" ,e#. I! 5.1. Re""," $(!"," ,e#. I! 7.".1. L",""," $(! ,e#. ""' :
0-003 0-005 0-007
2. K"$"'( II 3. K"$"'( III 4. K"$"'( I .L",""," $(! ,e# K#&e,:
0-003 0-004 0-006 0-008 0-01 0-003 0-003 0-75 0-025
1. K"$"'( I 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I 13.".L", e"&"( ,e#. Se!e'+"" Se!e'+"" .1.L",.e"&"( ,e# K#&e, 14 ..1.Te'(" ,&$.,e# ,#&e, B.1..Be'$" ,e#"&" '"" B.
L","," $" #e'(( ,e.
V PENUNJANG PELAYANAN KEP
0-35 1 0-014 0-014 0-014 0-014
B.3..A$" ",$( '"("( #'e( ..Pee'$" e("'/&,","'" Ke#/,e ;.. B(( "& III Ke#./Ke . B(( "& S I / I Ke# I. . N(&"( / )( "& III Ke#/ ,e . N(&"( / )( "& S I / I ,e#
N"#'"+- <<<<<<<< Mee$"+( : Ke#"&" R"
Pe"="( >" Be'",$"Be'", $"-
HAK A.K. 80% 100%
LAPORAN BULANAN PELAYANAN KEPERAWATAN JABATAN FUNGSIONAL PERAWAT AHLI TAHUN
N A M A N I P . JABAT AN PANGKAT / GOLONGAN
NO I
BUTIR KEGIATAN
PENDIDIKAN
A.1. Me!"#"$ e&"' / ()"*"+ S"')"" Ke# B.e. Me!"#"$," STTPL- &""" 81 160 )" . Me!"#"$," STTPL- &""" 30 80 )"
II
PELAYANAN KEPERAWATAN
A.1.". Me&",""," ",e# (!((! 3.1. Me'," !("" ,e#. I!((! 5.1. Me'e""," $(!"," ,e#. I!((! 7.".1. Me&",""," $(!"," ,e#. ""' : 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I .Me&",""," $(!"," ,e#. K#&e, : 1. K"$"'( I 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I 13.".Me&",""," e"&"( ,e#. Se!e'+"" .1.L",""," e"&"( ,e#. K#&e, (! 14..1.Mee'(" ,&$"( ,e# ,#&e, (! B.1..Be'$" e""( ,e#"&" '"" B.
Me&","," $" e""( #e'(( ,e.
V PENUNJANG PELAYANAN KEPERAWATAN
: : : :
U($ '"("( P'#(( JUMLAH PRESTASI KERJA SEMESTER I JAN
PEB
MAR
APR
MEI
JUN
: :
JUMLAH
KET
B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" e("'/&,","'" (!. Ke#./,e. ;.. Me(( "& III Ke#./Ke . Me(( "& S I / I Ke# I. . Me(&"( / e)( "& III Ke#. / ,e . Me(&"( / e)( "& S I / I ,e#
N"#'"+- <<<<<<<< Mee$"+( : Ke#"&" R"
Pe"="( " e'",$"-
LAPORAN BULANAN PELAYANAN KEPERAWATAN JABATAN FUNGSIONAL PERAWAT AHLI TAHUN
N A M A N I P . JABAT AN PANGKAT / GOLONGAN
NO I
BUTIR KEGIATAN
PENDIDIKAN
A.1. Me!"#"$ e&"' / ()"*"+ S"')"" Ke# B.e. Me!"#"$," STTPL- &""" 81 160 )" . Me!"#"$," STTPL- &""" 30 80 )"
II
PELAYANAN KEPERAWATAN
A.1.". Me&",""," ",e# (!((! 3.1. Me'," !("" ,e#. I!((! 5.1. Me'e""," $(!"," ,e#. I!((! 7.".1. Me&",""," $(!"," ,e#. ""' : 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I .Me&",""," $(!"," ,e#. K#&e, : 1. K"$"'( I 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I 13.".Me&",""," e"&"( ,e#. Se!e'+"" .1.Me&",""," e"&"( ,e#. K#&e, (! 14..1.Mee'(" ,&$"( ,e# ,#&e, (! B.1..Be'$" e""( ,e#"&" '"" B.
Me&","," $" e""( #e'(( ,e.
V PENUNJANG PELAYANAN KEPERAWATAN
: : : :
U($ '"("( P'#(( JUMLAH PRESTASI KERJA SEMESTER II JUL
AGS
SEP
OKT
NOP
DES
: :
JUMLAH
KET
B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" e("'/&,","'" (!. Ke#./,e. ;.. Me(( "& III Ke#./Ke . Me(( "& S I / I Ke# I. . Me(&"( / e)( "& III Ke#. / ,e . Me(&"( / e)( "& S I / I ,e#
N"#'"+-<<<<<<<< Mee$"+( : Ke#"&" R"
Pe"="( " e'",$"-
N A M A N I P . PANGKAT / GOL. RUANG JABATAN UNIT KRJA
: :
REKAPITULASI NILAI ANGKA KREDIT TENAGA FUNGSIONAL PERAWAT AHLI
NO
SEMESTER ( PERIODE )
PENDIDIKAN
PELAYANAN
1
2
3
4
U N S U R PENGEMBANGAN PENGABDIAN PROFESI MASYARAKAT
5
6
PENUNJANG
J U M LA H
7
8
JUMLAH
N"#'"+- <<<<<<<< Mee$"+( : T( Te,+( A," K'e!($
L"#('"
: KPUTUSAN BRSAMA MNTRI KS;ATAN AN KPALA BAAN KPGA?AIAN NGARA NOMOR
: 733/MNKS/SKB/I/2002
NOMOR
: 10 TA;UN 2002
TANGGAL
:
14 JUNI 2002
DAFTAR USUL PENETAPAN ANGKA KREDIT JABATAN TENAGA PERAWAT BIDANG KETERAMPILAN NOMOR : ……………………………………………………………. INSTANSI :
MASA PENILAIAN :
I
KETERANGAN PERORANGAN
1 2 3 4 5 6 7 8
N"" NIP. N. Se'( KARPG P","$ !" G&" R" / Te'+($ &"( $""& Te#"$ !" $""& &"+(' Je( Ke&"( Pe!(!(," $e'$(( J""$" $e"" #e'"="$" / Te'+($ &"( $""&
II
UNSUR YANG DINILAI
1
ANGKA KREDIT MENURUT INSTANSI PENGUSUL TIM PENILAI
UNSUR UTAMA DAN SUB UNSUR LAMA I
PENDIDIKAN
A.1. Me!"#"$ e&"' / ()"*"+ S1 Ke#e'"="$" B.e. M@!"#"$," STTPL- &""" 81 160 )" . M@!"#"$," STTPL- &""" 30 80 )"
J U M L A H II
PELAYANAN KEPERAWATAN
A.1.". Me&",""," ",e# (!((! 3.1. Me'," !("" ,e#. I!((! 4.1. Me'e""," $(!"," ,e#. I!((! 5.". Me&",""," $(!"," ,e#. ""' :
BARU
JUMLAH
LAMA
BARU
JUMLAH
1. K"$"'( II 2. K"$"'( III 3. K"$"'( I .Me&",""," $(!"," ,e#. K#&e, : 1. K"$"'( I 2. K"$"'( II 3. K"$"'( III 4. K"$"'( I 13.".Me&",," e"&"( ,e#e'"="$" e!'+"" 13..Me&",," e"&"( ,e#e'"="$" ,#&e, 14..Me&",," ,&$"( ,e#. K#&e, B.1..Be'$" e""( ,e#"&" '"" B.1..Be'$" e""( #e'(( ,ee+"$"
J U M L A H
2
ANGKA KREDIT MENURUT INSTANSI PENGUSUL TIM PENILAI
UNSUR PENUNJANG DAN SUB UNSUR LAMA
V
PENUNJANG PELAYANAN KEPERAWATAN
B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" e("'/&,","'" (!. Ke#./,e. ;.. Me(( "& III Ke#./Ke ;.. Me(( "& S1 Ke#e'"="$" I. . Me(&"( / e)( "& III Ke#. / ,e I. . Me(&"( / e)( "& S1 Ke#e'"="$"
J U
M L A H
JUMLAH BESAR
3
LAMPIRAN - LAMPIRAN USUL 1 . IJACA; TRAK;IR 2 . SK TRAK;IR 3 . SK UNGSIONAL 4 . KARPG 5 . P3
BARU
JUMLAH
LAMA
BARU
JUMLAH
6 7 8
.SRTIIKAT . PAK TRAK;IR N"#'"+- <<<<<<<< Dir!"#r
4
$ATATAN TEAM PENILAI JABATAN TENAGA PERAWATAN
N"#'"+- <<<<<<<< K"#% Ti& P'i%i Pr*i'+i,
5
<<<<<<<<<<<<<<. NIP.
$ATATAN PEJABAT PENILAI JABATAN TENAGA PERAWATAN
N"#'"+- <<<<<<<<
<<<<<<<<<<<<<. NIP.
