LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor 445/.........../2021. Kepala UPTD Puskesmas Langsa Barö
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada:

1. Nama : ...............................................................................................................................
NIP : ...............................................................................................................................
Jabatan : ......................................................................................................................
.........
No. SPPD : ...............................................................................................................................

2. Nama : ...............................................................................................................................
NIP : ...............................................................................................................................
Jabatan : ......................................................................................................................
.........
No. SPPD : ...............................................................................................................................

3. Nama : ...............................................................................................................................
NIP : ...............................................................................................................................
Jabatan : ......................................................................................................................
.........
No. SPPD : ...............................................................................................................................

Tugas : ...............................................................................................................................
Tujuan : ...............................................................................................................................
Lama Tugas : ...............................................................................................................................
Tanggal Berangkat : ...............................................................................................................................
Selesai Tugas : ...............................................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .....................................................................................................
2. Topik : .....................................................................................................
..................................................................................................... ...
..................................................................................................

3. Sasaran : .....................................................................................................
..................................................................................................... .
....................................................................................................
..................................................................................................... ..
...................................................................................................

4. Hambatan yang di hadapi : .....................................................................................................

..................................................................................................... .
....................................................................................................
..................................................................................................... ..
...................................................................................................

5. Saran : .....................................................................................................
.....................................................................................................
.....................................................................................................
..................................................................................................... .....
................................................................................................
 6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
..........................................................................................
Target :.........................................................................................
..........................................................................................
Pencapaian :.........................................................................................

.........................................................................................

Jumlah sasaran :........................................................................................

Demikian laporan kegiatan luar gedung ini dibuat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, ………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Siti Zubaidah, AM.Keb )

Pembina / NIP.197300813 199301 2 001 NIP. 19800225 200312 2 003
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor 445 /......./2021. Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada:

1. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

2. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

Tugas : ................................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .......................................................................................
2. Topik : .......................................................................................
.........................................................................................
.........................................................................................

3. Sasaran : .......................................................................................
.........................................................................................
.........................................................................................
........................................................................................
........................................................................................

4. Hambatan yang di hadapi : .......................................................................................

.........................................................................................
.........................................................................................
........................................................................................
........................................................................................

5. Saran : .......................................................................................
.........................................................................................
.........................................................................................
........................................................................................
6.
........................................................................................
 6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
..........................................................................................
Target : .........................................................................................
..........................................................................................
Pencapaian : .........................................................................................

.........................................................................................

Jumlah sasaran : ........................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, …………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Fahrani, AM.Keb )

Pembina / NIP.197300813 199301 2 001 NIP. 19810313 200504 2 001 19720220
199301 2 001
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor .445/.............../2021 Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada:

1. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
2.Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
3. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
4. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

Tugas : ................................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .......................................................................................
2. Topik : .......................................................................................
.......................................................................................
.......................................................................................

3. Sasaran : .......................................................................................
.......................................................................................
.......................................................................................
......................................................................................
......................................................................................

4. Hambatan yang di hadapi : .......................................................................................

.......................................................................................
.......................................................................................
......................................................................................
......................................................................................
 6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
..........................................................................................

…………………………………………………………..
Target :.........................................................................................
..........................................................................................
Pencapaian :.........................................................................................

.........................................................................................

Jumlah sasaran :........................................................................................

Demikian laporan kegiatanluar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, …………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Lindawaty,AM.Keb )

Pembina / NIP.197300813 199301 2 001 NIP.19730306 199302 2 003129720220
199301 2 001
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor 445/ ........../2021 Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada:

1. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
2. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
3. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
4.Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
5.Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
6.Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD :…………………………………………………………………………
7.Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
Tugas : ..............................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .......................................................................................
2. Topik : .......................................................................................
.......................................................................................
.......................................................................................

3. Sasaran : .......................................................................................
.......................................................................................
........................................................................................
........................................................................................
 ......................................................................................
4. Hambatan yang di hadapi : .......................................................................................
........................................................................................

5. Saran : ........................................................................................
.......................................................................................
.......................................................................................
........................................................................................
........................................................................................

6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
.........................................................................................
Target :........................................................................................
..........................................................................................
Pencapaian :.......................................................................................

........................................................................................

Jumlah sasaran :.......................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, …………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Erlina,A.Md.Keb )

Pembina / NIP.197300813 199301 2 001 NIP. 19710429 199302 2 00119720220
199301 2 001
 6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
.........................................................................................
Target :........................................................................................
..........................................................................................
Pencapaian :.......................................................................................

........................................................................................

Jumlah sasaran :.......................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa,
Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita.SKM ) (Susi Safriani,A.Md.Keb)

Pembina/NIP.19740511 200504 2 001 NIP. 19761212 2007012002
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor 445 /........./ 2021.Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada :

1. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
2. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................
3. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

Tugas : ................................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .......................................................................................
2. Topik : .......................................................................................
.......................................................................................
.......................................................................................

3. Sasaran : .......................................................................................
.......................................................................................
........................................................................................
.......................................................................................
.......................................................................................

4. Hambatan yang di hadapi : .......................................................................................

........................................................................................
........................................................................................
........................................................................................
........................................................................................

5. Saran : ........................................................................................
........................................................................................
........................................................................................
 ........................................................................................
........................................................................................

6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
.........................................................................................
Target :........................................................................................
..........................................................................................
Pencapaian :.......................................................................................

........................................................................................

Jumlah sasaran :.......................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa,
Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita.SKM ) (Yuni Lena, A.Md. Keb)

Pembina/NIP.19740511 200504 2 001 NIP. 19710429 1999302 2 001
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor 445/ ........./2021Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada :

1. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

2. Nama : ...............................................................................................................
Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

Tugas : ................................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

1. Program : .......................................................................................
2. Topik : .......................................................................................
.......................................................................................
.......................................................................................

3. Sasaran : .......................................................................................
.......................................................................................
........................................................................................
.......................................................................................
.......................................................................................

4. Hambatan yang di hadapi : .......................................................................................

........................................................................................
........................................................................................
........................................................................................
........................................................................................
........................................................................................
 5. Saran : ........................................................................................
........................................................................................
........................................................................................
........................................................................................
........................................................................................

6. Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
.........................................................................................
Target :........................................................................................
..........................................................................................
Pencapaian :.......................................................................................

........................................................................................

Jumlah sasaran :.......................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa,
Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita.SKM ) (DitaWidya, A.Md. Keb)

Pembina/NIP.19740511 200504 2 001 NIP. 19880826 201705 2 003
 LAPORAN KEGIATAN LUAR GEDUNG

Berdasarkan Surat Perintah Tugas Nomor ...................................Kepala UPTD Puskesmas Langsa Baro
Kecamatan Langsa Barӧ Pemerintah Kota Langsa, dengan ini memberikan tugas kepada :

1.Nama : ...............................................................................................................

Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

2.Nama : ...............................................................................................................

Nip : ...............................................................................................................
Jabatan : ...............................................................................................................
No. SPPD : ...............................................................................................................

Tugas : ................................................................................................................
Tujuan : ...............................................................................................................
Lama Tugas : ...............................................................................................................
Tanggal Berangkat : ...............................................................................................................
Selesai Tugas : ...............................................................................................................

Dalam pelaksanaan Kegiatan

7. Program : .......................................................................................
8. Topik : .......................................................................................
.......................................................................................
.......................................................................................

9. Sasaran : .......................................................................................
.......................................................................................
........................................................................................
.......................................................................................
.......................................................................................

10. Hambatan yang di hadapi : .......................................................................................

........................................................................................
........................................................................................
........................................................................................
........................................................................................
........................................................................................
 11. Saran : ........................................................................................
........................................................................................

6 .Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
..........................................................................................
Target : .........................................................................................
..........................................................................................
Pencapaian : .........................................................................................

.........................................................................................

Jumlah sasaran : ........................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, …………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Sufia Dahniati, AMd.Keb )

Pembina / NIP.197300813 199301 2 001 NIP. 19810313 200504 2 001 19720220
199301 2 001
 6 .Hasil yang di kegiatan :

Petugas : ........................................................................................
..........................................................................................
..........................................................................................
Target : .........................................................................................
..........................................................................................
Pencapaian : .........................................................................................

.........................................................................................

Jumlah sasaran : ........................................................................................

Demikian laporan kegiatan luar gedung ini di buat dan dapat dipertanggung jawabkan oleh pengelola
Program.

Mengetahui: Langsa, …………………………

Kepala UPTD Puskesmas Langsa Barӧ Yang Melaksanakan Kegiatan

( Safrita, SKM ) ( Intan Khastuti, AMd.Keb )

Pembina / NIP.197300813 199301 2 001 NIP. 19851109 201705 2 001 19720220
199301 2 001