LAPORAN LAPORA N HARIAN HA RIAN KEGIATAN PELAYANAN PELAYANAN KEPERAWAT KEPERAWATAN AN JABATAN FUNGSIONAL PERAWAT AHLI
N A M A N I P . PANGK ANGKA AT / GOLO GOLON NGAN GAN 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 RGANISA NISASI 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"$"'( I 13.".L", e"&"( ,e#. Se!e'+"" .1.L",.e"&"( ,e# K#&e, 1 4..1.Te'(" ,&$.,e # ,#&e, B.1..Be'$" ,e#"&" '"" B.
L","," $" #e'(( ,e.
V PENUNJANG PELAYANAN KEP B.3..A$" ",$( '"("( #'e( ..Pee'$" e("'/&,","'" Ke#/,e ;.. B(( "& III Ke#./Ke . B(( "& S I / I Ke# I. . N(&"( / )( "& III Ke#/ ,e . N(&"( / )( "& S I / I ,e#
Mee$"+( : Ke#"&" R"
0-35 1 0-014 0-014 0-014 0-014 Se"'"- <<<<<<<<<<<<.. Pe"="( >" Be'",$"Be'", $"-
HAK A.K. 80% 100%
LAPORAN BULANAN PELAYANAN KEPERAWATAN JABATAN FUNGSIONAL PERAWAT AHLI TAHUN
N A M A N I P . JABAT AN PANGKAT / GOLONGAN
NO
BUTIR KEGIATAN
I PENDIDIKAN A.1. Me!"#"$ 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
: : : :
U($ '"("( P'#((
: :
JUMLAH PRESTASI KERJA SEMESTER I JUMLAH JAN PEB MAR APR MEI JUN
KET
LAPORAN BULANAN PELAYANAN KEPERAWATAN JABATAN FUNGSIONAL PERAWAT AHLI TAHUN
N A M A N I P . JABAT AN PANGKAT / GOLONGAN
NO
BUTIR KEGIATAN
: : : :
U($ '"("( P'#((
: :
JUMLAH PRESTASI KERJA SEMESTER I JUMLAH JAN PEB MAR APR MEI JUN
I 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&","," $" e""( #e'(( ,e.
V PENUNJANG PELAYANAN KEPERAWATAN B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" e("'/&,","'" (!. Ke#./,e. ;.. Me(( "& III Ke#./Ke . Me(( "& S I / I Ke# I. . Me(&"( / e)( "& III Ke#. / ,e . Me(&"( / e)( "& S I / I ,e#
Se"'"- <<<<<<<< Mee$"+( : Ke#"&" R"
Pe"="( " e'",$"-
KET
LAPORAN BULANAN PELAYANAN KEPERAWATAN JABATAN FUNGSIONAL PERAWAT AHLI TAHUN
N A M A N I P . JABAT AN PANGKAT / GOLONGAN
NO
BUTIR KEGIATAN
: : : :
U($ '"("( P'#(( JUMLAH PRESTASI KERJA SEMESTER II JUL AGS SEP OKT NOP DES
: :
JUMLAH
I 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&","," $" e""( #e'(( ,e.
V PENUNJANG PELAYANAN KEPERAWATAN B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" e("'/&,","'" (!. Ke#./,e. ;.. Me(( "& III Ke#./Ke . Me(( "& S I / I Ke# I. . Me(&"( / e)( "& III Ke#. / ,e . Me(&"( / e)( "& S I / I ,e#
Se"'"- <<<<<<<< Mee$"+( : Ke#"&" R"
Pe"="( " e'",$"-
KET
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
Se"'"- <<<<<<<<<<<< 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 KETERAMPIL NOMOR : ……………………………………………………………. INSTANSI : RSU TUGUREJO SEMARANG I
MASA PENILAIAN :
KETERANGAN PERORANGAN
1 2 3 4 5 6 7
N"" NIP. N. Se'( KARPG P","$ !" G&" R" / Te'+($ &"( $""& Te#"$ !" $""& &"+(' Je( Ke&"( Pe!(!(," $ $( (
L"#('"
: KPUTUSAN BRSAMA MNTRI KS;ATAN AN KPALA BAAN KPGA?AIAN NGARA NOMOR
: 733/MNKS/SKB/I/2002
NOMOR
: 10 TA;UN 2002
TANGGAL
:
14 JUNI 2002
DAFTAR USUL PENETAPAN ANGKA KREDIT JABATAN TENAGA PERAWAT BIDANG KETERAMPIL NOMOR : ……………………………………………………………. INSTANSI : RSU TUGUREJO SEMARANG I
MASA PENILAIAN :
KETERANGAN PERORANGAN
1 2 3 4 5 6 7 8
N"" NIP. N. Se'( KARPG P","$ !" G&" R" / Te'+($ &"( $""& Te#"$ !" $""& &"+(' Je( Ke&"( Pe!(!(," $e'$(( J""$" $e"" #e'"="$" / Te'+($ &"( $""&
II
UNSUR YANG DINILAI
1
ANGKA KREDIT MENURUT INSTANSI PENGUSUL TIM PENIL
UNSUR UTAMA DAN SUB UNSUR LAMA I
PENDIDIKAN
A.1. Me!"#"$ 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&",""," $(!"," ,e#. ""' : 1. K"$"'( 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+"$"
J U M L A H
BARU
JUMLAH
LAMA
BARU
2
UNSUR PENUNJANG DAN SUB UNSUR
V
PENUNJANG PELAYANAN KEPERAWATAN
ANGKA KREDIT MENURUT INSTANSI PENGUSUL TIM PENIL LAMA BARU JUMLAH LAMA BARU
B.3..Me)"!( "$" ",$( '"("( #'e( .. Pee'$" 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 6 .SRTIIKAT 7 . PAK TRAK;IR 8
Se"'"- <<<<<<<<<< Dir!"#r
4
$ATATAN TEAM PENILAI JABATAN TENAGA PERAWATAN
Se"'"- <<<<<<<<<< K"#% Ti& P'i%i Pr*i'+i,
5
$ATATAN PEJABAT PENILAI JABATAN TENAGA PERAWATAN
<<<<<<<<<<<<<<. NIP.
Se"'"- <<<<<<<<<<
<<<<<<<<<<<<<. NIP.
N
I JUMLAH
I JUMLAH
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