170498_formulir%20permohonan%20survey%20%20pendahuluan%20%202019.docx

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KEMENTRIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS PALANGKA RAYA FAKULTAS KEDOKTERAN Kampus UPR Tunjung Nyaho Jalan Yos Sudarso Palangka Raya (73111) Kalimantan Tengah Telp/fax. : (0536) 421 5402, 421 5277, 421 5179 Laman : www.fk-upr.ac.id E-mail : prodifk.upr @gmail.com

FORMULIR PERMOHONAN SURAT IZIN SURVEY PENDAHULUAN 1. Nama 2. NIM 3. Judul 4. 5. 6. 7.

Tempat/Lokasi Penelitian Pembimbing I Pembimbing II Tujuan permohonan data

: Mikhael Jevon Dandan : FAA 115 050 : Prevalensi dan Faktor Resiko Kejadian Rinitis Alergi Akibat Polusi Asap di Kota Palangkaraya : Kota Palangkaraya : dr. Moelyadhi Oetomo, Sp.THT : drg. Agnes Frethernety, M.Biomed : 1. Dinas Kesehatan Kota Palangkaraya 2. Rumah Sakit Doris Sylvanus Palangkaraya

8. Data yang dicari

: 1. Data Prevalensi Angka Kejadian Rinitis Alergi Di Palangkaraya Tahun 2014-2016 2. Data Prevalensi Angka Kejadian ISPA Di Palangkaraya Tahun 2014-2016

Palangka Raya, Februari 2019 Pembimbing,

(

Mahasiswa,

)

(Mikhael Jevon Dandan) NIM. FAA 115 035

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