4.1.1.5 Bukti Pelaksanaan Soaialisasi Kegiatan.docx
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DAFTAR HADIR SOSIALISASI PELAKSANAAN KEGIATAN UKM UPTD PUSKESMAS CIGASONG KABUPATEN MAJALENGKA HARI TANGGAL TEMPAT MATERI NO
:...................................................... :...................................................... :..................................................... :...................................................... NAMA
JABATAN
ALAMAT
TANDA TANGAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Mengetahui, Kepala Uptd Puskesmas Cigasong
Cigasong,.............................. Pembuat Daftar
OO TAOFIK, SKM.,MM NIP: 198011072008031004
..............................................
NOTULEN Rapat
: ..............................................................................................................
Hari/ tanggal
: ..............................................................................................................
Tanggal undangan
: ..............................................................................................................
Waktu Rapat
: ...................................................WIB s.d Selesai
Acara
: ...................................................agenda Terlampir 1. 2. 3. 4.
Isi absensi peserta Materi :.................................................................. Diskusi/ Kesepakatan Penutup/ Do’a
Pimpinan Rapat
: ...................................................................................................................
ketua
: ..................................................................................................................
sekretaris
: ...................................................................................................................
Peserta rapat
:
Kegiatan rapat
: 1. Isi absensi peserta : undangan hadir sejumlah ...........orang Undangan terlampir 2. Persentasi :...............................................Materi Terlampir 3. Diskusi/ kesepakatan : Kesepakatan terlampir 4. Penutup /do’a
1. Kata pembukaan
: ...............................................................................................................
2. Pembahasan
: .................................................................................................................
Jumlah peserta......orang absensi terlampir
................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. ................................................................................................................... ................................................................................................................... ..................................................................................................................
.................................................................................................................. .................................................................................................................. ................................................................................................................... ................................................................................................................... 3. Peraturan
: Dibuat kesepakatan bersama dan ditindaklanjuti
Cigasong, ...................................................... Notulen
........................................................................... NIP:...............................................................
KESEPAKATAN
Rapat
:....................................................................................................................
Hari/ tanggal
:....................................................................................................................
Tanggal undangan
:...................................................................................................................
Waktu rapat
:...................................................................................................................
1. ................................................................................................................................................. 2. ................................................................................................................................................. 3. ................................................................................................................................................. 4. ................................................................................................................................................. 5. ................................................................................................................................................. 6. ................................................................................................................................................. 7. ................................................................................................................................................. 8. ................................................................................................................................................ 9. ................................................................................................................................................ 10. ................................................................................................................................................
Cigasong,.................................. Pelaksana kegiatan
............................................................ NIP:......................................................
DOKUMENTASI KEGIATAN
:...................................................... :...................................................... :..................................................... :...................................................... NAMA
JABATAN
ALAMAT
TANDA TANGAN
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Mengetahui, Kepala Uptd Puskesmas Cigasong
Cigasong,.............................. Pembuat Daftar
OO TAOFIK, SKM.,MM NIP: 198011072008031004
..............................................
NOTULEN Rapat
: ..............................................................................................................
Hari/ tanggal
: ..............................................................................................................
Tanggal undangan
: ..............................................................................................................
Waktu Rapat
: ...................................................WIB s.d Selesai
Acara
: ...................................................agenda Terlampir 1. 2. 3. 4.
Isi absensi peserta Materi :.................................................................. Diskusi/ Kesepakatan Penutup/ Do’a
Pimpinan Rapat
: ...................................................................................................................
ketua
: ..................................................................................................................
sekretaris
: ...................................................................................................................
Peserta rapat
:
Kegiatan rapat
: 1. Isi absensi peserta : undangan hadir sejumlah ...........orang Undangan terlampir 2. Persentasi :...............................................Materi Terlampir 3. Diskusi/ kesepakatan : Kesepakatan terlampir 4. Penutup /do’a
1. Kata pembukaan
: ...............................................................................................................
2. Pembahasan
: .................................................................................................................
Jumlah peserta......orang absensi terlampir
................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. .................................................................................................................. ................................................................................................................... ................................................................................................................... ..................................................................................................................
.................................................................................................................. .................................................................................................................. ................................................................................................................... ................................................................................................................... 3. Peraturan
: Dibuat kesepakatan bersama dan ditindaklanjuti
Cigasong, ...................................................... Notulen
........................................................................... NIP:...............................................................
KESEPAKATAN
Rapat
:....................................................................................................................
Hari/ tanggal
:....................................................................................................................
Tanggal undangan
:...................................................................................................................
Waktu rapat
:...................................................................................................................
1. ................................................................................................................................................. 2. ................................................................................................................................................. 3. ................................................................................................................................................. 4. ................................................................................................................................................. 5. ................................................................................................................................................. 6. ................................................................................................................................................. 7. ................................................................................................................................................. 8. ................................................................................................................................................ 9. ................................................................................................................................................ 10. ................................................................................................................................................
Cigasong,.................................. Pelaksana kegiatan
............................................................ NIP:......................................................
DOKUMENTASI KEGIATAN
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