PE JABATAN FUNG PUSKESMAS
:
TAHUN PENILAIAN
:
CIMARAGAS KECAMATAN
DATA DASAR FORMAT S.K.P TARGET
2014
ENTRY NILAI SURAT TUGAS
FORMAT PENGUKURAN SEMESETER 1 FORMAT PENGUKURAN SEMESETER 2 FORMAT PENGUKURAN 1 TAHUN PANDUAN JENJANG JABATAN PERAWAT PANDUAN ANGKA KREDIT KUMULATIF
BUKU CATATA
PANDUAN NILAI TU DAN KREA
ILAIAN SASARAN KERJA PEGAWAI SIONAL TERTENTU (JFT) SANITARIA NAMAPETUGAS
PANGATIKAN
:
JABATAN
KEGIATAN
:
URAIAN KEGIATAN P1
AMBAHAN
PERILAKU
AS TAMBAHAN IFITAS
JANUARI
JULI
FEBRUARI
AGUSTUS
MARET
SEPTEMBER
APRIL
OKTOBER
MEI
NOPEMBER
JUNI
DESEMBER
TERAMPIL Bagu Mu!"#a! Pa$a Sa%&!a'&a% Pa*a%a P+ua
B, : A-&$%a A.I./A%
JUMLAH ANGKA KREDIT KUMULATIF MINIMAL UNTUK PE SANITARIAN T JENJAN NO
R USN U
PERSENTASE
SANITARIAN. PEMULA
II/a 1
UNSUR UTAMA A. Pendidikan
≥ 80%
B. Penyehatan Lingkungan
20
C. Pengembangan Profesi 2
UNSUR PENUNJANG
≤ 0 %
Kegiatan Penunjang Tugas Sanitarian JUMLAH
100%
5 25
JUMLAH ANGKA KREDIT KUMULATIF MINIMAL UNTUK PE SANITARIAN JENJANG NO
R USN U
PERSENTASE
PER
III/a 1
UNSUR UTAMA A. Pendidikan B. Penyehatan Lingkungan
≥ 80%
80
C. Pengembangan Profesi 2
UNSUR PENUNJANG Kegiatan Penunjang Tugas Sanitarian JUMLAH
≤ 0 % 100%
20 100
GANGKATAN DAN KENAIKAN JABATAN/ PANGKAT RAMPIL JABATAN, GOLONGAN, RUANG DAN ANGKA KREDIT SANITARIAN TINGKAT TERAMPIL SANITARIAN. PELAKSANA LANJUTAN
SANI TAR IAN .PEL AK SAN A
SAN ITAR IAN .PEN Y EL I A
II/b
II/
II/!
III/a
III/b
III/
III/!
25
8
!
80
120
1!0
20
8
12
1!
20
"0
0
!0
""
#0
$0
100
150
200
"00
GANGKATAN DAN KENAIKAN JABATAN/ PANGKAT AHLI JABATAN, GOLONGAN, RUANG DAN ANGKA KREDIT SANITARIAN TINGKAT AHLI AM A
MU D A
M AD YA
III/b
III/
III/!
I/a
I/b
I/
120
1!0
20
"20
0
5!0
"0
0
!0
80
110
10
150
200
"00
&00
550
'00
MENU
NAMA INSTNASI TAHUN PENILAIAN
NO
I
1
Nama
2
NIP
3
Pangkat/Gol.Ruang
4
Jabatan
5
Unit Kerja
NO
AT
1
Nama
2
NIP
3
Pangkat/Gol.Ruang
4
Jabatan
5
Unit Kerja
I.
(IMARAGAS KE(AMATAN PANGATIKAN 201&
P
EJABP AE T NILAI
NO
II.
1
Nama
2
NIP
P#$%&%' III() K#*%+% T%&% U,%-%
3
Pangkat/Gol.Ruang
4
Jabatan
P,/#,%, C/
5
Unit Kerja
SAPNEJABA PTENILAI
NO
II.
H3. A S4 S$%4,-' S.K#*' M.S
1
Nama
1!1225 120" 2 002
2
NIP
P#$%&% ( III.C
3
Pangkat/Gol.Ruang
K#*%+% P,/#,%,
4
Jabatan
P,/#,%, C%4%6%, K#)%%&%$ P%$6%&/%$
5
Unit Kerja
MENU PEGA)AI NEGERI SIPIL YANG DINILAI
B%6, M&7%& P%,-% 1!1"12 189011 001 P#$%&%' III() S%$&%4%$ P#+%/,%$% P#+% P,/#,%, C/
PEGA)AI NEGERI SIPIL YANG DINILAI
B%6, M&7%& P%,-% 1!1"12 189011 001 P#$%&%' III() S%$&%4%$ P#+%/,%$% P#+% P,/#,%, C/
III / A
URA A IN
JUMLAHPOINT
SATUAN
A!"KA K#$&T T$#AK'
200
P(&!T
K$B)T)'A! A!"KA K#$&T *&!&*AL
"00
P(&!T
S&SA A.K +" 'A#)S &CAPA&
100
P(&!T
P$#KAA! T$#CAPA& ALA* S$*$ST$#
5
S$*$ST$#
K$B)T)'A! ALA* P$# S$*$ST$#
20.00
P(&!T
JUMLAH KEBUTUHAN TARGET A.K SKP DALAM STU TAHUN
&0.00
POINT
FORMULI PEGAW NO
PI.EJABAPTENILAI
1
Nama
0
2
NIP
0
3
Pangkat/Gol.Ruang
PenataIII/!
4
Jabatan
Ke"ala #ata U$a%a
5
UnitKerja
Pu$ke$ma$&ibiuk
NO
IIIK . EGIATANTUGASJABATAN
'em"er$ia"kan Pelak$anaan Kegiatan Ke$e%atan (ingkungan 'elakukan Pengamatan Ke$e%atan (ingkungan 'elakukan Penga)a$an Ke$e%atan (ingkungan *Pemerik$aan Kualita$ Ke$e%atan (ingkungan+ 'elakukan Penga)a$an Ke$e%atan (ingkungan *#in,ak (anjut Penga)a$an + 'ember,a-akan 'a$-arakat ,alam 'eningkatkan Kualita$ Ke$e%atan (ingkungan 'embimbing anitarian ,i ba)a% Jenjang Jabatann-a 'engajar / 'elati% "a,a "en,i,ikan ,an "elati%an "ega)ai $etia" 2 jam "elajaran 'engikuti $eminar / lokakar-a ,alam bi,ang keNI#RIN an / ke$e%atan $ebagai Pemra$arana 'engikuti $eminar / lokakar-a ,alam bi,ang keNI#RIN an / ke$e%atan $ebagai 'o,erator 'engikuti $eminar / lokakar-a ,alam bi,ang keNI#RIN an / ke$e%atan $ebagai Pe$erta 'enja,i angota #im Penilai Jabatan ung$ional NI#RIN 'elak$anakan Kegiatan (inta$ Program ,an (inta$ ektoral (ainn-a *Ikut erta alam kegiatan organi$a$i $o$ial *(K' Pramuka PKK Karang #aruna ,ll+ #ia" rgani$a$i KEGIATAN YANG DIBERIKAN KEPALA PUSKESMAS
'embuat Ren!ana #a%unan Program Ke$ling 'ela"orkan %a$il kegiatan "rogram Ke$ling ulanan ke"a,a Ke"ala Pu$ke$ma$ JUMLAH AK
C%&%&%$ : ; AK B%6 PNS <%$6 #%$6/ 3%%&%$ =$6,7$%+ $&
P#3%%& P#$+%'
0 !&P.
0
SASARAN KERJA I NEGERI SIPIL NO
II.PEGA)AINEGERISIPILYANGDINILAI
1
Nama
agu$ 'utoat Pa$%a
2
NIP
1641312 178011 001
3
Pangkat/Gol.Ruang
PenataIII/!
4
Jabatan
5
UnitKerja
anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
TARGET AK K U AN T / O U T P U T
K U AL / M U T U
)AK T U
1.718 0
17 0
(a"oran (a"oran
100 100
12 12
ulan ulan
0
0
(a"oran
100
12
ulan
0
0
(a"oran
100
12
ulan
0
0
(a"oran
100
12
ulan
0
0
(a"oran
100
12
0
0
0
0
erti9ikat
100
12
ulan
0
0
erti9ikat
100
12
ulan
0
0
erti9ikat
100
12
0
0
urat #uga$
100
12
ulan
0
0
urat Keterangan nggota
100
12
ulan
0
0
(a"oran
100
12
ulan
0
0
(a"oran
100
12
ulan
urat #uga$
100
12
ulan ulan
ulan
1.718
"arut,
P#6%>% N#6#4 S*+ Y%$6
Bagu Mu!"#a! Pa$ !&P. 1!1"12 189011 00
BIAYA
: : : : : : : : : : : :
: :
201 $+%
a 1
PENILAIAN AP PEGAWAI NO
PE I.JABP AE TNILAI
1
Nama
2
NIP
3
Pangkat/Gol.Ruang
4
Jabatan
5U
0 0 Penata III/! Ke"ala #ata U$a%a
Kerja nit
Pu$ke$ma$ &ibiuk
-angka aktu Peni/aian -anuari s.d. 1 esember 02 TARGET NO
IK . * + a - a T + a J a b a - a
1
2
0
'em"er$ia"kan Pelak$anaan Kegiatan Ke$e%atan (ingkungan
0
'elakukan Pengamatan Ke$e%atan (ingkungan
0
'elakukan Penga )a$an Ke$e% atan (in gkungan *Pem erik$aan Kualit a$ Ke$e% atan (in gkungan+
0
'elakukan Penga)a$an Ke$e%atan (ingkungan *#in,ak (anjut Penga)a$an +
0
'ember,a-akan 'a$-arakat ,alam 'eningkatkan Kualita$ Ke$e%atan (ingkungan
0
'elak$anakan Kegiatan (inta$ Program ,an (inta$ ektoral (ainn-a *Ikut erta alam kegiatan organi$a$i $o$ial *(K' Pramuka PKK Karang #aruna ,ll+ #ia" rgani$a$i
AK K a - /O- -
K a / M -
4
)
1.718
17
(a"oran
100
12
0
0
(a"oran
100
12
0
0
(a"oran
100
12
0
0
(a"oran
100
12
0
0
(a"oran
100
12
0
0
urat Keterangan nggota
100
12
0
0
(a"oran
100
12
0
0
(a"oran
100
12
K;GI#N <NG I;RIKN K;P( PUK;'
0
0
'embuat Ren!ana #a%unan Program Ke$ling
'ela"orkan %a$il kegiatan "rogram Ke$ling ulanan ke"a,a Ke"ala Pu$ke$ma$
II. TUGAS TAMBAHAN DAN KREATIITAS/UNSUR PENUNJANG 4
1 2 3 4 5
Na (aaa
P#3%%& P#$+%'
0 !&P.
0
IAN SASARAN KERJA NEGERI SIPIL NO
II.PEGA)AINEGERISIPILYANGDINILAI
1
Nama
agu$ 'utoat Pa$%a
2
NIP
1641312 178011 001
3
Pangkat/Gol.Ruang
PenataIII/!
4
Jabatan
5
UnitKerja
anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
REALISASI AK a 3- 3
PENGHITUNGAN
B aa
K a -O / - 6
K a / M -
)a 3-
10
11
B a a
5
ulan
:
0.876
10
(a"oran
75
6
ulan
10
11
ulan
:
0.3456
12
(a"oran
75
6
ulan
=I>/0?
ulan
:
0
0
(a"oran
75
6
ulan
=I>/0?
ulan
:
0
0
(a"oran
75
6
ulan
=I>/0?
ulan
:
0
0
(a"oran
75
6
ulan
=I>/0?
ulan
:
0
0
urat Keterangan nggota
75
6
ulan
=I>/0?
ulan
:
0
0
(a"oran
75
6
ulan
=I>/0?
ulan
:
0
0
(a"oran
75
6
ulan
=I>/0?
266.56
SKP 201
"arut,
P#6%>% N#6#4 S*+ Y%$6 D$+%
Ba+ M-67a- Pa8a !&P. 1!1"12 189011 001
NILAI (APAIAN SKP 12
77.75 =I>/0? =I>/0? =I>/0? =I>/0?
=I>/0?
=I>/0?
=I>/0?
9DI/0: 9DI/0:
PE
NO
PE I.JABP AE TNILAI
1
Nama
2
NIP
3
Pangkat/Gol.Ruang
4
Jabatan
5U
0 0 Penata III/! Ke"ala #ata U$a%a
Kerja nit
Pu$ke$ma$ &ibiuk
-angka aktu Peni/aian -anuari s.d. 1 esember 02 NO
IK . * + a -a T + a J a b a - a
AK Ka-/ O--
1
0
0
0
0
0
0
2
4
'em"er$ia"kan Pelak$anaan Kegiatan Ke$e%atan (ingkungan 1.718
17
(a"oran
0
0
(a"oran
0
0
(a"oran
0
0
(a"oran
0
0
(a"oran
0
0
urat Keterangan
'elakukan Pengamatan Ke$e%atan (ingkungan
'elakukan Penga )a$an Ke$e%a tan (in gkungan *Pem erik$aan Kuali ta$ Ke$e %atan (ingku ngan+
'elakukan Penga)a$an Ke$e%atan (ingkungan *#in,ak (anjut Penga)a$an +
'ember,a-akan 'a$-arakat ,alam 'eningkatkan Kualita$ Ke$e%atan (ingkungan
'elak$anakan Kegiatan (inta$ Program ,an (inta$ ektoral (ainn-a *Ikut erta alam kegiatan organi$a$i $o$ial *(K' Pramuka PKK Karang #aruna ,ll+ #ia" rgani$a$i
nggota II. TUGAS TAMBAHAN DAN KREATIITAS/UNSUR PENUNJANG 4
1 2 3 4 5
P#3%%& P#$+%'
!&P.
0 0
ILAIAN APAIAN SASARAN KERJA PEGAWAI NEGERI SIPIL NO 1 2N
TARGET K a / M -
agu$ 'uto
IP
1641312 1
3
Pangkat/Gol.Ruang
4
Jabatan
anitarian P
5
Unit Kerja
Pu$ke$ma$
3
B a a
K a -O / - -
5
PenataIII/!
REALISASI
AK )a 3-
IP I.EGA)A NIEG Nama
6
K a / M -
)a 3-
10
11
100
12
ulan
:
0
0
(a"oran
75
6
ulan
100
12
ulan
:
0
0
(a"oran
75
6
ulan
100
12
ulan
:
0
0
(a"oran
75
6
ulan
100
12
ulan
:
0
0
(a"oran
75
6
ulan
100
12
ulan
:
0
0
(a"oran
75
6
ulan
100
12
ulan
:
0
0
urat Keterangan
75
6
ulan
nggota
Na (aaa SKP "arut,
P#6%>% N#
Ba+ !&P. 1!1"
ERI SIPIL YANG DINILAI at Pa$%a 78011 001
MENU elak$ana Pemula &ibiuk
PENGHITUNGAN
NILAI (APAIAN SKP
11
12
Baa 10
211.00
80.33 =I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
=I>/0?
9DI/0: 9DI/0:
201 #4 S*+ Y%$6 D$+%
M-67a- Pa8a
2 189011 001
P#%6 %/-4 ,#,% ?#$6%$ 3 /#6%&%$ *#4 67+7$6%
+%-
NO 1
1. Nama
2
2.NIP
3
3. Pangkat/Gol.Ruang
4
4. Jabatan
5
5..UnitKerja
NO
A
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& % ) ? # =
B
@ !0 J% !1 ,(? !0 J% 81 ,(? 80 J% 1!1 ,(? 80 J% 81 ,(? 1!0 J% "0 ,(? 80 J%
PELA7ANAN K ESANITARIAN A N 1M +-'&a-*a% P a*a%aa% K % % ) ? #
M#$<,$ 4#$)%$% &%-$%$ TOR M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ M#$<,$ 4%$)%$6%$ &$6/%& K# M#$<%3/%$ 4%$)%$6%$ &$6/%& K M#$<#*4$%/%$ 4%$)%$6%$ &$
= M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ &
2 Ma*u*a% P %ga+a!a% K $a % 'engum"ulkan ba%an untuk "er$ia"an ,alam "e
NO ) ? #
'elakukan "engum"ulan ,ata "rimer 'elakukan "engm"ulan ,ata $ekun,er 'elakukan "engola%an ,ata $e!ara manual 'elakukan "engola%an ,ata ,engan alat bantu el
Ma*u*a% P %ga;aa% K $a % Pemerik$aan kualita$ ke$e%atan lingkungan ob-e Pemerik$aan kualita$ ke$e%atan lingkungan ob-e ) 'elakukan "emerik$aan ob-ek kelom"ok II $e,er ? 'elakukan "emerik$aan ob-ek kelom"ok II kon@ # = 6 3
'elakukan "emerik$aan ob-ek kelom"ok II !ang 'engambil $am"el ,an $"e!imen ob-ek kelom"o 'engambil $am"el ,an $"e!imen ob-ek kelom"o 'engambil $am"el ob-ek kelom"ok II $e,er%ana 'engambil $am"el ob-ek kelom"ok II kon@en$ion 'engambil $am"el ob-ek kelom"ok II !anggi%
4 Ma*u*a% P %ga;aa% K $a % #in,ak lanjut "enga)a$an menentukan ,iagno$a #in,ak lanjut "enga)a$an menentukan ,iagno$a ) #in,ak lanjut "enga)a$an menentukan ,iagno$a ? # = 6
#in,ak lanjut "enga)a$an menentukan ,iagno$a #in,ak lanjut "enga)a$an menentukan ,iagno$a #in,ak lanjut "enga)a$an menentukan ,iagno$a #in,ak lanjut "enga)a$an menentukan ,iagno$a Kon$ulta$i ke$e%atan lingkungan ob-ek kelom"o Kon$ulta$i ke$e%atan lingkungan ob-ek kelom"o
M+'.a,a*a% Ma,a'a*a! .a % ) ? # = 6
Per$ia"an kegiatan i,enti9ika$i "erilaku membuat
3 / +
'enganali$i$ lanjut Ke$im"ulan ,an la"oran Kegiatan
Per$ia"an kegiatan i,enti9ika$i "erilaku membuat Per$ia"an kegiatan i,enti9ika$i "erilaku mengum" Per$ia"an kegiatan i,enti9ika$i "erilaku mengum" 'enganali$a "erilaku tabula$i ,an "engum"ulan 'enganali$a "erilaku tabula$i ,an "engum"ulan 'enganali$i$ e,er%ana
'embuat "eren!anaan "ember,a-aan ma$-arak 'embuat "eren!anaan "ember,a-aan ma$-arak 'embuat "engembangan materi $e,er%ana 'embuat "engembangan materi lanjut
NO $ 7 * 4 , & > <
'em"er$ia"kan ,an memeli%ara alat "eraga 'elakukan "ember,a-aan in,i@i,u umum 'elakukan "ember,a-aan in,i@i,u "oten$ial 'embuat "er!onto%an "ember,a-aan ma$-arak 'embuat la"oran %a$il "ember,a-aan 'enggerakan ,an menggerakan kelom"ok ma$'enggerakan ,an menggerakan kelom"ok ma$Pelak$anaan "enggerakan kon$ulta$i ,engan "ej Pelak$anaan "enggerakan "ertemuan linta$ $ekt Pelak$anaan "enggerakan ka,er Pelak$anaan "enggerakan melati% ka,er Pelak$anaan "enggerakan membina ka,er Pelak$anaan "enggerakan membimbing $ur@ei ,
3 M+&+&%g Sa%&!a'&a% .& a;a
PENUNJANG PELA7ANAN KESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.& 5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
KEGIATAN 7ANG DIBERIKAN KEPALA P 1M +ua! R%
K#*%+% P,/#,%,
NO
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA KEGIATAN KESANITARIAN AN I. PEJABAT PENILAI 0
Nama
0
1.
NIP
Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
2. Pangkat/G 3. Jabatan 4. 5..Unit Kerja
T
UNSUR DAN BUTIR KEGIATAN A=K
u.a9A*a.+&*9DIII
0
$a%Gu%g&"%a.&&.a%gK$a!a%.g%+%.a-a!STTPL
0 0 0 0 0 0 0
g&a!a% K$a!a% L&%g*u%ga%
)
1=51
&$6/%& K#)%%&%$(P,/#,%, K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, %%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, K#)%%&%$(P,/#,%, %& $6/%& K#)%%&%$(P,/#,%,
L&%a g% *u%ga% gum"ulan ,ata
0.029 0.059 0 0 0 0 0.0! 1.2!92 0.08"2
0 0
T
UNSUR DAN BUTIR KEGIATAN A=K 0 0 0 0
ektronik
a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%)
0
k kelom"ok I $e,er%ana
0
k kelom"ok I kon@en$ional %ana
0 0 0 0 0 0 0 0 0
n$ional i% k II $e,er%ana k II ko@en$ional al
a%L&%g*u%ga%(T&%.a*La%8u!P%ga;aa%)
0 0 0 0
,an treatment inter@en$i ob-ek kelom"ok I a)al $e,er%ana ,an treatment inter@en$i ob-ek kelom"ok I a)al kon@en$ional ,an treatment inter@en$i ob-ek kelom"ok I lanjut $e,er%ana
0 0 0 0 0 0
,an treatment inter@en$i ob-ek kelom"ok I lanjut kon@en$ional ,an treatment inter@en$i ob-ek kelom"ok II a)al $e,er%ana ,an treatment inter@en$i ob-ek kelom"ok II a)al kon@en$ional ,an treatment inter@en$i ob-ek kelom"ok II a)al !anggi% I a)al lokal I a)al regional
a+M%&%g*a!*a%Kua&!aK$a!a%L&%g*u%ga% in$trumen $e,er%ana in$trumen lanjut ulkan ,ata "rimer ulkan ,ata $ekun,er ata $e,er%ana ata lanjut
at $e,er%ana at lanjut
0 0 0 0 0 0 0 0 0 0 0 0 0 0
T
UNSUR DAN BUTIR KEGIATAN A=K
$a $en,iri
0 0 0 0 0 0 0 0 0 0 0 0 0
$ J%8a%g Jaa!a%%,a
0
t rakat "oten$ial "engum"ulan ,ata tentang ma$ala% ke$e%atan rakat "oten$ial tabula$i ,an "engola%an ,ata abat ber)enang/toko% ma$-arakat/toko% agama r
N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
0
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a
0
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"'
0
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a
0
a% Fu%g&"%a SANITARIAN
0
'"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
0
SKESMAS 'a+ K&%g
0
a+ K&%g Bua%a% *-a.a K-aa Pu*+a
0
JUMLAH ANGKA KREDIT
1=51
T
UNSUR DAN BUTIR KEGIATAN A=K
ERAMPIL II. PEGA)AI NEGERI SIPIL YANG DINILAI agu$ 'utoat Pa$%a 1641312 178011 001 ol.Ruang
PenataIII/! anitarian Pelak$ana Pemula Pu$ke$ma$ &ibiuk
DIISI KOLOM 7ANG BERWARNA KUNING RGET
SEMESTERI
KUANTITAS9 OUTPUT
A=K
KUANTITAS9 OUTPUT
SEMESTERII A=K
KUANTITAS9 OUTPUT
PENILAIAN1TAHUN A =K
KUANTITAS9 OUTPUT
0
0
0
0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0=653
10
0=02 0=0 0 0 0 0 0=2045 0=33 0=052
1 1 0 0 0 0 2 3 1
0=43
12
0
0
0000000
15
0=653
10
0
1 1
0.029 0.059 0 0 0 0
1 1
0 0 0 0 0 0
12 1
0.208 0.!""! 0.08"2
2 ! 1
0 0 0
0
0=43
12
0
0
0
0
0
RGET
SEMESTERI
KUANTITAS9 OUTPUT
KUANTITAS9 OUTPUT
0 0 0 0
0 0 0=43 0
0 0 12 0
0
0
0
0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0 0 0 0
0 0 0."5! 0
12
A=K
KUANTITAS9 OUTPUT
PENILAIAN1TAHUN A =K
A=K
KUANTITAS9 OUTPUT
SEMESTERII
0000000
0000000
0000000
RGET KUANTITAS9 OUTPUT
SEMESTERI A=K
KUANTITAS9 OUTPUT
SEMESTERII A=K
KUANTITAS9 OUTPUT
PENILAIAN1TAHUN A =K
KUANTITAS9 OUTPUT
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1=242
0
1=242
"arut,
P#6%>% N#6#4 S*+ Y%$6 D$+%
201
RGET KUANTITAS9 OUTPUT
SEMESTERI A=K
SEMESTERII
KUANTITAS9 OUTPUT
A=K
KUANTITAS9 OUTPUT
PENILAIAN1TAHUN A =K
Bagu Mu!"#a! Pa$a !&P. 1!1"12 189011 001
KUANTITAS9 OUTPUT
MENU
SANITARIAN PELAKSANA PEMULA
SANITARIAN PELAKSANA
SANITARIAN PELAKSANA LANJUTAN
SANITARIAN PENYELIA
30
30
30
30
30
1 6 3 2 1
15 !!!! """" 2222 1111
15
15
15
0.028
0.028
0.028
0.028
0.058
0.058
0.058
0.058
0.0512
0.064
0.064
0.064
0.16
0.16
0.20
0.20
0.0224
0.027
0.027
0.027
SANITARIAN PENYELIA
0=02 0=0 0=012 0=13 0=0224 0=144 0=1024 0=103 0=052
0=03
0.144
0.144
0.17
0.17
0.1024
0.127
0.127
0.127
0.1056
0.132
0.132
0.132
0.0732
0.104
0.104
0.104
0.06
0.06
0.06
0.06
SANITARIAN PENYELIA
0=024 0=002 0=0255 0=03
SANITARIAN PELAKSANA PEMULA
SANITARIAN PELAKSANA
SANITARIAN PELAKSANA LANJUTAN
SANITARIAN PENYELIA
0.024
0.024
0.024
0.024
0.0082
0.00
0.00
0.00
0.0277
0.036
0.036
0.036
0.056
0.056
0.08
0.08
0=015
0.017
0.017
0.017
0.017
0=025 0=0224 0=034 0=13 0=006 0=024 0=0162 0=03 0=125
0.027 0.0224
0.027 0.027
0.027 0.027
0.027 0.027
0.064
0.064
0.07
0.07
0.16
0.16
0.16
0.2
0.00
0.00
0.00
0.00
0=006 0=0125 0=04 0=05 0=0125 0=02 0=144 0=0125 0=02
0=112 0=0162 0=02 0=0162 0=02 0=023 0=045 0=02 0=0034 0=162 0=125 0=0034 0=013
0.024
0.024
0.024
0.024
0.012
0.024
0.024
0.024
0.056
0.056
0.08
0.08
0.127
0.127
0.127
0.16
0.00
0.00
0.00
0.00
0.0127
0.016
0.016
0.016
0.04
0.04
0.05
0.05
0.07 0.0127
0.07 0.016
0.07 0.016
0.10 0.016
0.032
0.032
0.04
0.04
0.144
0.144
0.144
0.17
0.0127
0.016
0.016
0.016
0.032
0.032
0.04
0.04
0.112
0.112
0.112
0.140
0.012
0.024
0.024
0.024
0.032
0.04
0.04
0.04
0.012
0.024
0.024
0.024
0.082
0.082
0.0
0.0
0.0256
0.032
0.032
0.032
0.047
0.047
0.06
0.06
0.032 0.0064
0.032 0.007
0.04 0.007
0.04 0.007
0.12
0.12
0.24
0.24
0.127
0.16
0.16
0.16
0.0064
0.007
0.007
0.007
0.016
0.016
0.02
0.02
SANITARIAN PELAKSANA PEMULA
SANITARIAN PELAKSANA
SANITARIAN PELAKSANA LANJUTAN
SANITARIAN PENYELIA
0.032
0.032
0.032
0.04
0.047
0.047
0.047
0.06
0.64
0.64
0.64
0.7
0.0256
0.032
0.032
0.032
0.076
0.112
0.112
0.112
0.112
0.112
0.14
0.14
0.017
0.017
0.017
0.017
0.0127
0.016
0.016
0.016
0.0447
0.056
0.056
0.056
0.167
0.167
0.21
0.21
0.047
0.047
0.06
0.06
0.12
0.12
0.24
0.24
12.5
12.5
12.5
12.5
0=02
0.02
0.02
0.02
0.02
0=04
0.04
0.04
0.04
0.04
SANITARIAN PENYELIA
0=02 0=045 0=34 0=023 0=0563 0=112 0=015 0=0125 0=0445 0=135 0=045 0=162 12=
3333
2
2222
1
1111
0=
0.5
0.5
0.5
0.5
0=
0.5
0.5
0.5
0.5
0=04
0.04
0.04
0.04
0.04
3333
SANITARIAN PENYELIA
SANITARIAN PELAKSANA PEMULA
SANITARIAN PELAKSANA
SANITARIAN PELAKSANA LANJUTAN
SANITARIAN PENYELIA
PE
NO
PE I.JABP AE TNILAI
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;rrA50
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II. TUGAS TAMBAHAN DAN KREATIITAS/UNSUR PENUNJANG 4
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P#3%%& P#$+%'
0 !&P.
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ILAIAN APAIAN SASARAN KERJA PEGAWAI NEGERI SIPIL NO 1 2N
TARGET K a / M -
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10
11
100
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ulan
:
0.876
10
(a"oran
75
12
ulan
100
12
ulan
:
0.3456
12
(a"oran
75
12
ulan
100
12
ulan
:
0
0
(a"oran
75
12
ulan
100
12
ulan
:
0
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(a"oran
75
12
ulan
100
12
ulan
:
0
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100
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100
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100
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75
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100
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75
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1.3242
0
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75
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ulan
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P#6%>% N#
Ba+ !&P. 1!1"
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at Pa$%a 78011 001 elak$ana Pemula &ibiuk
PENGHITUNGAN
NILAI (APAIAN SKP
11
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Baa 10
216.56
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BULAN : NO A
B
UN S PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P %.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% P a*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K $a % P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ ) M#+%//%$ *##4/,%%$ 7<#/ / ? M#+%//%$ *##4/,%%$ 7<#/ / # M#+%//%$ *##4/,%%$ 7<#/ / = M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7
NO A
UN S PENDIDIKAN DAN PELATIHAN 4 Ma*u*a% P %ga;aa% K $a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4%
7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%& < P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.& 5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
NO A
UN S PENDIDIKAN DAN PELATIHAN K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR KEGIATAN PE I. JABP AT ENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
II. Nama NIP
1. 2. 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
KGIATAN 7ANG BERWARNA KUNING
R DAN BUTIR KEGIATAN 124 u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%,
0
0
)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, L&a%%g*u%ga% 0 ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) 0 +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$667<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66-
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
R DAN BUTIR KEGIATAN a%L&%g*u%ga%(T&%.a*La%8u!P%ga;aa%) $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ $&/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ 7<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+
124 0 0 0 /#+7*7/ I %>%+ ,#?#4-%$% /#+7*7/ I %>%+ /7$#$,7$%+ /#+7*7/ I +%$3& ,#?#4-%$% /#+7*7/ I +%$3& /7$#$,7$%+ /#+7*7/ II %>%+ ,#?#4-%$% /#+7*7/ II %>%+ /7$#$,7$%+ /#+7*7/ II %>%+ )%$66-
a+M%&%g*a!*a%Kua&!aK$a!a%L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
0
0
0
0
0
0
0
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a% aa+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a aa+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' aa+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (LKMD@ P
R DAN BUTIR KEGIATAN
124
PEGA)AI NEGERI SIPIL YANG DINILAI
MEN
agu$ 'utoat Pa$%a 1641312 178011 001 Penata III/! anitarian Pelak$ana Pemula Pu$ke$ma$ &ibiuk
TANGGAL KEGIATAN 3
5
6
0000000000000000
0000000000000000
0000000000000000
0000000000000000
10
11
12
1
14
1
13
1
15
16
20
21
3
5
6
10
11
12
1
14
0000000000000000
0000000000000000
'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
TANGGAL KEGIATAN 1 13 1 15
16
20
21
3
5
6
10
11
12
1
14
TANGGAL KEGIATAN 1 13 1 15
16
20
21
U
JUMLAH 22
2
24
2
23
2
25
26
0
1
TOTAL
0
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0 0 0 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
JUMLAH TOTAL
22
2
24
2
23
2
25
26
0
1
0
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0
0
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22
2
24 "arut,
2
23
2
25
26
0
201 P#6%>% N#6#4 S*+ Y%$6 D$+%
!&P.
B%6, M&7%& P%,-% 1!1"12 189011 001
1
JUMLAH TOTAL
PERKIRAAN JUMLAH
PERKIRAAN JUMLAH
KEGIATAN HARIAN 1 SEMESTER
KEGIATAN HARIAN 1 TAHUN
1= 2=0 0=0 0=0 0=0 0=0 0=0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0
0 =0 0 =5 0 =1 0 =1
E'':06 E'':06 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 =0 0 =0 0 =0 0 =0 0 =2 0 = 0 =1 1 =0 0 =0 0 =0 0 =0 1 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
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1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
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T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
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MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
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B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
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1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
MENU
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
MENU
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
MENU
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
5 M%g&*u!& +&%a' 9 "*a*a',a . 6 M%g&*u!& +&%a' 9 "*a*a',a . 10 M%g&*u!& +&%a' 9 "*a*a',a . 11M %8a.& a%g"!a T&+ P%&a& Jaa 12M a*a%a*a% Kg&a!a% L&%!a P
K#*%+% P,/#,%,
H;. A S< S=a<8, S.K*, M.S !&P.
1!1225 120" 2 002
ENTR7 DATA HARIAN BUTIR I. PEJABAT PENILAI 0 0 Penata III/! Ke"ala #ata U$a%a Pu$ke$ma$ &ibiuk
DIISI KGIATAN 7ANG BERWARNA KUNING
UNSUR DAN BUTIR KEGIATAN u.a9A*a.+&*9DIII $a% Gu%g&"%a .&&.a%g K$a!a% .g% +%.a-a! STTPL
g&a!a% K$a!a% L&%g*u%ga% K#)%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, %%&%$(*,/#,%, )%%&%$(P,/#,%, /%& K#)%%&%$(P,/#,%, 6/%& K#)%%&%$(P,/#,%, %& K#)%%&%$(P,/#,%, $6/%& K#)%%&%$(P,/#,%, a% L&%g*u%ga% ,%*%$ ?%+% *#$6*+%$ ?%&% #4 $?#4 4% %$%+ 6%$ %+%& %$& #+#/&47$/ a% L&%g*u%ga% (P+'&*aa% Kua&!a K$a!a% L&%g*u%ga%) +$6/$6%$ 7<#/ /#+7*7/ I ,#?#4-%$% +$6/$6%$ 7<#/ /#+7*7/ I /7$#$,7$%+ #+7*7/ II ,#?#4-%$% #+7*7/ II /7$#$,7$%+ #+7*7/ II )%$66-
7<#/ /#+7*7/ II ,#?#4-%$% 7<#/ /#+7*7/ II /7#$,7$%+ 7/ II ,#?#4-%$% 7/ II /7$#$,7$%+ 7/ II )%$66a% L&%g*u%ga% (T&%.a* La%8u! P%ga;aa% ) &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ I +%$3& /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ ,#?#4-%$% &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ /7$#$,7$%+ &/%$ ?%6$7,% ?%$ &4#%&#$& $#$, 7<#/ /#+7*7/ II %>%+ )%$667<#/ /#+7*7/ I %>%+ +7/%+ 7<#/ /#+7*7/ I %>%+ 4#67$%+ a+ M%&%g*a!*a% Kua&!a K$a!a% L&%g*u%ga% 4+%/ #%& $,&4#$ ,#?#4-%$% 4+%/ #%& $,&4#$ +%$3& 4+%/ #$6*+/%$ ?%&% *4#4 4+%/ #$6*+/%$ ?%&% ,#/$?#4 $ *#$6*+%$ ?%&% ,#?#4-%$% $ *#$6*+%$ ?%&% +%$3&
%<%%$ %,<%4%/%& ,#?#4-%$% %<%%$ %,<%4%/%& +%$3& ,#?#4-%$% +%$3& %+%& *#4%6% *7$,%+ <%%$ %,<%4%/%& %<%%$ /#+7*7/ %,<%4%/%& *7$,%+ *#$6*+%$ ?%&% $&%$6 %,%+%- /#,#-%&%$ /#+7*7/ %,<%4%/%& *7$,%+ &%+%, ?%$ *#$67+%-%$ ?%&% +&%, ?#$6%$ *#3%%& #4>#$%$6(&7/7- %,<%4%/%&(&7/7- %6%% %$ +$&%, ,#/&74 - /%?#4 $% /%?#4 $6 ,4# ?#,% ,#$?4 $ J%8a%g Jaa!a%%,a N AN *a% .a% -a!&$a% -ga;a& !&a- 2 8a+ -a8a'a%
a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P+'aa'a%a a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& M".'a!"' a+ &.a%g *SANITARIAN a% 9 *$a!a% aga& P'!a a% Fu%g&"%a SANITARIAN '"g'a+ .a% L&%!a S*!"'a La&%%,a (I*u! S'!a Daa+ *g&a!a% "'ga%&a& "&a (
EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
agu$ 'utoat Pa$%a 1641312 178011 001 PenataIII/! anitarianPelak$anaPemula Pu$ke$ma$&ibiuk
T 1
2
4
00000000000000
00000000000000
00000000000000
00000000000000
3
5
6
10
11
12
1
14
00000000000000
00000000000000
LKMD@ P'a+u*a@ PKK@ Ka'a%g Ta'u%a@ .) T&a- O'ga%&a&
NGGAL KEGIATAN 1 13 1 15
00000000000000
00000000000000
00000000000000
00000000000000
16
20
21
22
2
24
2
23
2
25
00000000000000
00000000000000
"arut,
P#6%>% N#6#4 S*+ Y%$6
!&P.
B%6, M&7%& P%,1!1"12 189011 0
MENU
JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
NO 1 2 3 4 5
1. Nama 2. NIP 3. Pangkat/Gol.Ruang 4. Jabatan 5..Unit Kerja
BULAN : NO A
B
PENDIDIKAN DAN PELATIHAN 1 M%g&*u!& P%.&.&*a% Sa'8a%a M 2 M%g&*u!& P%.&.&*a% .a% Pa!& a > 630 Ja+ 341 9. 630 Ja+ < 451 9. 540 Ja+ . 131 9. 450 Ja+ 51 9. 130 Ja+ ? 0 9. 50 Ja+ PELA7ANAN KESANITARIAN AN 1M +-'&a-*a% Pa*a%aa% K % M#$67+%- ?%&% ,#?#4-%$% &$6/% M#$6%$%+,% ?%&% ,#?#4-%$% &$ ) M#$<,$ 4%$)%$6%$ &$6/%& K# ? M#$<%3/%$ 4%$)%$6%$ &$6/%& K # M#$<#*4$%/%$ 4%$)%$6%$ &$ = M#$<,$ 4#$)%$% " +%$%$ &$ 6 M#$<,$ 4#$)%$% +%$%$ &$6 6 M#$<,$ 4#$)%$% 7*#4%,7$%+ & 2 Ma*u*a% P %ga+a!a% K $a % M#$6*+/%$ %-%$ $&/ *#4 M#+%//%$ *#$6*+%$ ?%&% * ) M#+%//%$ *#$6*+%$ ?%&% ,# ? M#+%//%$ *#$67+%-%$ ?%&% ,#) # M#+%//%$ *#$67+%-%$ ?%&% ?#$ Ma*u*a% P %ga;aa% K$a % ) ? #
P##4/,%%$ /%+&%, /#,#-%&%$ P##4/,%%$ /%+&%, /#,#-%&%$ M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ / M#+%//%$ *##4/,%%$ 7<#/ /
= M#$6%+ ,%*#+ ?%$ ,*#)# 6 M#$6%+ ,%*#+ ?%$ ,*#)# - M#$6%+ ,%*#+ 7<#/ /#+7 M#$6%+ ,%*#+ 7<#/ /#+7 3 M#$6%+ ,%*#+ 7<#/ /#+7 4 Ma*u*a% P %ga;aa% K$a % T$?%/ +%$3& *#$6%>%,%$ #$# T$?%/ +%$3& *#$6%>%,%$ #$# ) T$?%/ +%$3& *#$6%>%,%$ #$# ? T$?%/ +%$3& *#$6%>%,%$ #$# # T$?%/ +%$3& *#$6%>%,%$ #$# = T$?%/ +%$3& *#$6%>%,%$ #$# 6 T$?%/ +%$3& *#$6%>%,%$ #$# - K7$,+&%, /#,#-%&%$ +$6/$6%$ K7$,+&%, /#,#-%&%$ +$6/$6%$ M+'.a,a*a% Ma,a'a*a! .a % P#4,%*%$ /#6%&%$ ?#$&/%, * P#4,%*%$ /#6%&%$ ?#$&/%, * ) P#4,%*%$ /#6%&%$ ?#$&/%, * ? P#4,%*%$ /#6%&%$ ?#$&/%, * # M#$6%$%+,% *#4+%/ &%+%, ?% = M#$6%$%+,% *#4+%/ &%+%, ?% 6 M#$6%$%+,, S#?#4-%$% - M#$6%$%+,, +%$3& K#,*+%$ ?%$ +%*74%$ K#6%&% 3 M#%& *#4#$)%$%%$ *##4? / M#%& *#4#$)%$%%$ *##4? + M#%& *#$6#%$6%$ % M#%& *#$6#%$6%$ % $ M#*#4,%*/%$ ?%$ ##+-%4% 7 M#+%//%$ *##4?%<%%$ $? * M#+%//%$ *##4?%<%%$ $? M#%& *#4)7$&7-%$ *##4? 4 M#%& +%*74%$ -%,+ *##4? , M#$66#4%/%$ ?%$ #$66#4%/%$ & M#$66#4%/%$ ?%$ #$66#4%/%$ P#+%/,%$%%$ *#$66#4%/%$ /7$, P#+%/,%$%%$ *#$66#4%/%$ *#4 > P#+%/,%$%%$ *#$66#4%/%$ /%?#4 P#+%/,%$%%$ *#$66#4%/%$ #+%&
< P#+%/,%$%%$ *#$66#4%/%$ # P#+%/,%$%%$ *#$66#4%/%$ # 3 M+&+&%g Sa%&!a'&a% .& a;a PENUNJANG P ELA7ANAN K ESANITARI M%ga8a' 9 Ma!&$ -a.a -%.&.&
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EGIATAN II. PEGA)AI NEGERI SIPIL YANG DINILAI 1.Nama 2.NIP 3. Pangkat/Gol.Ruang 4.Jabatan 5..UnitKerja
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JUMLAH TOTAL
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 SEMESTER
PERKIRAAN JUMLAH KEGIATAN HARIAN 1 TAHUN
0
0 0 0 0 0 0 0
1 = 2 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 E'':06 E'':06 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=5 0=1 0=1 0=0 0=0 0=0 0=0 0=2 0= 0=1 1=0 0=0 0=0 0=0 1=0
0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
26
0
1
0
0
0
0
0
0
0
0
0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0 0=0
0 0 0
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
0
0 0 0 0 0
201 D$+%
01
0 =0 0 =0 0 =0 0 =0 0 =0
0=0 0=0 0=0 0=0 0=0
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K<*a-C-a Na A3abi/a hasi/ yang ditemukan meru3akan sesuatu yang baru danbermanfa bagi unit kerjanya dan dibuktikan dengan suratketerangan yang ditandatangani o/eh ese/on && diberikan ni/ai. ke3a/a unit kerja atau 3ejabat
A3abi/a hasi/ yang ditemukan meru3akan sesuatu yang baru danbermanf bagi organisasinya serta dibuktikan dengan surat keterangan yang ditandatangani o/eh instansi yang setingkat diberikan ni/ai.3ejabat ese/on & atau 3im3inan
A3abi/a hasi/ yang ditemukan meru3akan sesuatu yang baru dan bermanfaat bagi !egara serta dibuktikan dengan surat 3enghargaan yang ditandatangani o/eh Presiden yang tertinggi diberikan ni/ai.
NILAI 1
5