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    This document is a request form for the procurement of goods. It details 15 items needed, including gloves, masks, gowns, and oximeters. The total estimated cost is 19,132,500 IDR. The items are requested by Dr. Nina in the SUBCON SHE/Global Doctor division and are needed for use at rapid test sites in February 2023 to help prevent the spread of COVID-19. The form requires approval from the general services department heads.

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    This document is a request form for the procurement of goods. It details 15 items needed, including gloves, masks, gowns, and oximeters. The total estimated cost is 19,132,500 IDR. The items are requested by Dr. Nina in the SUBCON SHE/Global Doctor division and are needed for use at rapid test sites in February 2023 to help prevent the spread of COVID-19. The form requires approval from the general services department heads.

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    © All Rights Reserved
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    13 views1 page

    LWKWIL

    Uploaded by

    dokter nina
    This document is a request form for the procurement of goods. It details 15 items needed, including gloves, masks, gowns, and oximeters. The total estimated cost is 19,132,500 IDR. The items are requested by Dr. Nina in the SUBCON SHE/Global Doctor division and are needed for use at rapid test sites in February 2023 to help prevent the spread of COVID-19. The form requires approval from the general services department heads.

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    of 1

    PT PAMAPERSADA NUSANTARA SRGS/19/F-001

    JAKARTA 1/1

    FORM
    PERMINTAAN PENGADAAN BARANG

    NAMA : dr. Nina

    NRP

    DIVISI / DEPARTEMEN : SUBCON SHE/ GLOBAL DOCTOR

    KATEGORI BUDGET ALLOCATION


    TANGGAL TANGGAL
    No ITEM BARANG JUMLAH UOM SPESIFIKASI RENCANA KEPERLUAN ESTIMASI HARGA TOTAL RENCANA
    DIGUNAKAN Extracomptable Asset (EA) PEMENUHAN
    Budget UnBudget
    / Fixed Asset (FA)

    (a) (b) (C) (d) (e) (f) (g) (h) (i) (j) (k) (l)
    1 SARUNG TANGAN UKURAN S 10 BOX MERK = NITRILE Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 112.500 IDR 1.125.000

    2 SARUNG TANGAN UKURAN M 36 BOX MERK = NITRILE Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 112.500 IDR 4.050.000

    3 SARUNG TANGAN UKURAN L 3 BOX MERK = NITRILE Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 112.500 IDR 337.500

    4 SARUNG TANGAN UKURAN S 6 BOX MERK = SENSI Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 112.500 IDR 675.000

    5 SARUNG TANGAN UKURAN M 10 BOX MERK = SENSI Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 112.500 IDR 1.125.000

    6 SURGICAL MASK EARLOOP 26 BOX MERK = ONEMED, 50'S Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 37.500 IDR 975.000

    7 SURGICAL MASK HEADLOOP (HIJAB) 5 BOX MERK = ONEMED, 50'S Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 37.500 IDR 187.500

    8 SURGICAL MASK EARLOOP 26 BOX MERK = SOFTIES, 30'S Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 97.500 IDR 2.535.000

    9 SURGICAL MASK HEADLOOP (HIJAB) 5 BOX MERK = SOFTIES, 30'S Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 97.500 IDR 487.500

    10 GOWN 13 Pcs MERK = MEDISCRUB Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 405.000 IDR 5.265.000

    11 FACESHIELD 15 PCS FACESHIELD BUKA TUTUP Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 18.000 IDR 270.000

    12 PLASTIK SAMPAH MEDIS (WARNA KUNING) 8 PACK UKURAN = 40x60cm, Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 45.000 IDR 360.000

    13 OXIMETER 3 Pcs MERK = GENERAL CARE Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 345.000 IDR 1.035.000

    14 PULPEN 8 BOX PEN GEL JOYKO 0,5 mm Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 60.000 IDR 480.000

    15 PLASTIK KLIP OBAT 10 PACK UKURAN = 10X15 CM, ADA ETIKET Feb-23 EA - COVID 19 POS RAPID HO, CILE, CILI IDR 22.500 IDR 225.000

    Total 1.728.000 19.132.500

    Pemohon : General Services


    Diajukan Oleh : Disetujui oleh : Diperiksa Oleh : Diperiksa oleh Disetujui oleh :
    1 2 3 4 5

    Pemohon Atasan PIC Budget PIC Purchasing GS Section Head / Dept Head

    Catatan :

    (a) - (h) = diisi oleh pemohon Kategori Aset

    (i) = diisi oleh PIC Budget GS Nilai Barang 500.000 sd 4.999.999 = Extracomptable Asset - OPEX Budget

    (j) = diisi oleh PIC Purchasing GS Nilai Barang > 5.000.000 = Fixed Asset - CAPEX Budget

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