Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 2

LAPORAN PELAKSANAAN TUGAS

1. Dasar Penugasan : Surat Perintah Puskesmas


Nomor : 800/ /PKM-PR/2019
Tanggal ..………… 2019
2. Nama Petugas : ………………………………………
3. Tujuan Perjalanan : ………………………………………
4. Tanggal Perjalanan : ………………………………………
5. Maksud Perjalanan : ………………………………………
6. Hasil Kunjungan
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….

7. Permasalahan yang dihadapi


……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….

8. Rencana Tidak Lanjut


……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….
……………………………………………………………………………………………………….

Bogor, ………………… 2019


Tempat yang dikunjungi Yang melaksanakan

( ) ( )
LAMPIRAN SURAT TUGAS
Nomor :

CAP &
NO TANGGAL LOKASI TUJUAN
TANDA TANGAN

You might also like