Form Pemusnahan Obat

DAFTAR OBAT YANG DIMUSNAHKAN NO INJEKSI 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

NAMA OBAT Piracetam inj 1 gr Hexilon Inj Simdrol Inj Citicolin Inj Nokoba Inj Sibital Inj Cefazolin Inj Biosave Farmavon Tomit Cernevit Levosol NTG Catapres Ketorolac 1 % Cefotaxim Chrome Boraginol L-N supp Piracetam inj 3 gr Vopicain Terfaref Cordarone Morfin Cedocard Vagizol supp Durogesic Patch

JUMLAH

ALASAN PEMUSNAHAN

170 amp 6 Amp 3 vial 59 Amp 21 Amp 20 Amp 120 Amp 1 Vial 17 Amp 7 Amp 5 Vial 12 Amp 10 Amp 18 Amp 30 Amp 4 Vial 1 Vial 37 Supp 13 Amp 10 Vial 4 Vial 51 Amp 21 Amp 2 Amp 28 Supp 18 Patch

Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date

Saksi-saksi 1......................................................... NIP.

2. ..................................................... NIP.

............................................20......... yang membuat berita acara yang membuat berita acara ........................................................... NO.SIPA

DAFTAR OBAT YANG DIMUSNAHKAN NO SYRUP 1 2 3 4 5 6 7 8

NAMA OBAT Sim DHA Azytromicin Cefat Calnic Alocair Plus Gel Infimycin Cefadroxil Chloramfenicol

SALEP/TETES 9 Elox Salp 10 Cendo Caterlant MDS 11 Cendo Pospo MDS

JUMLAH

ALASAN PEMUSNAHAN

10 11 11 6 2 6 1 52

Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date

3 36 34

Expire Date Expire Date Expire Date

DAFTAR OBAT YANG DIMUSNAHKAN NO TABLET 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

NAMA OBAT Lisinopril 5 MG Lisinopril 10 MG Ramipril tab Meloxin 15 MG Nuzym Tonicard Obimin AF Progynova 2 MG Sedrofen 500 MG Simarc 2 MG Rebamax Silum 5 MG Sanazet Simtin 10 MG Lanaven Harnal - D

JUMLAH ALASAN PEMUSNAHAN 500 500 933 230 230 1000 9 56 60 1000 58 83 10 119 22 68

Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date Expire Date