1 1 +
+ PEMERINTAH KABUPATEN CIREBONPEMERINTAH KABUPATEN CIREBON
DINAS KESEHATAN DINAS KESEHATAN
Jalan Sunan Muria No. 6 Telp (0231) 320273 Fax (0231) 320273 Jalan Sunan Muria No. 6 Telp (0231) 320273 Fax (0231) 320273 Website !in"es#$irebon."ab.%o.i! e&ail !in"es#$irebon."ab.%o.i! Website !in"es#$irebon."ab.%o.i! e&ail !in"es#$irebon."ab.%o.i!
Su&ber'611 Su&ber'611 *,-T-SN *,/ NS *STN *-,TN 45N *,-T-SN *,/ NS *STN *-,TN 45N NM5 NM5 Se"retariatSe"retariat TNTN8 TNTN8 TT NS* NS TT NS* NS /N8*-N8N NS *STN *-,TN 45N /N8*-N8N NS *STN *-,TN 45N *,/ NS *STN *-,TN *,/ NS *STN *-,TN CIREBON, CIREBON, Me
Menini&b&banan% % a.a. baba9:a 9:a !a!alala& & raran%n%"a "a &e&enunnun;a;an% n% "e"elalan$n$araran an pepelala"s"sananaanaan tu
tu%a%as s popo"o"o" " iinanas s *e*esese9a9atatan n !i !i bibi!a!an% n% a!a!&i&ininiststrarasisi ,e&erinta9an perlu pen<era%a&an pen%elolaan tata nas"a9 ,e&erinta9an perlu pen<era%a&an pen%elolaan tata nas"a9 !inas !i lin%"un%an inas *ese9atan=
!inas !i lin%"un%an inas *ese9atan= b.
b. baba9:a 9:a pepen<n<erera%a%a&a&an an tatata ta nanas"s"a9 a9 !i !i lilin%n%"u"un%n%an an iinasnas *ese9a
*ese9atan tan !isus!isusun un seba%aseba%ai i ba%iaba%ian n !ari upa<a !ari upa<a penin%penin%"atan"atan &utu pela<anan=
&utu pela<anan= $.
$. ba9ba9:a pen!o:a pen!o&an pen<u&an pen<usunsunan an tattata a nasnas"a9 &en%"a9 &en%a$u pa!aa$u pa!a peraturan <an% berla"u=
peraturan <an% berla"u= !.
!. ba9ba9:a ber!as:a ber!asar"ar"an pertian perti&ba&ban%an pa!a butin%an pa!a butir r a>b !an $ a>b !an $ !i!i atas> perlu &enetap"an "eputusan *epala inas *ese9atan atas> perlu &enetap"an "eputusan *epala inas *ese9atan tentan% ,e!o&an Tata Nas"a9 inas *ese9atan *abupaten tentan% ,e!o&an Tata Nas"a9 inas *ese9atan *abupaten 4irebon=
4irebon= M
Meenn%%iinn%%aatt 11.. --nn!!aann%%''uunn!!aann% % NNoo&&oor r 11 TTaa99uun n 220000? ? tteennttaann%% *eterbu"aan n@or&asi ,ubli" (/e&baran Ne%ara 5epubli" *eterbu"aan n@or&asi ,ubli" (/e&baran Ne%ara 5epubli" n
n!o!onenesisia a TaTa9un 9un 20200? 0? NoNo&o&or r 6161> > TaTa&b&ba9aa9an n /e/e&b&bararanan Ne%ara ?6)=
Ne%ara ?6)= 2.
2. ,e,eraratuturaran n ,e,e&e&eririntnta9 a9 NoNo&o&or r 2? 2? TaTa9u9un n 202012 12 tetentntanan%% ,e
,elala"s"sananaaaan n -n-n!a!an%n%'-'-n!n!anan% % NoNo&o&or r ? ? tata9u9un n 20200A0A ten
tentantan% % "ea"earsirsipan pan (le(le&ba&baran ran Ne%Ne%ara ara 5ep5epublubli" i" n!n!oneonesiasia Ta9un
Ta9un 2012 2012 No&or No&or ?> ?> ta&ba9an ta&ba9an le&baran le&baran Ne%araNe%ara 5epubli" n!onesia No&or 2?6)=
5epubli" n!onesia No&or 2?6)= 3.
3. ,eratu,eraturan Menteri ,en!a<a%uran Menteri ,en!a<a%unaan paratur Ne%ara No&ornaan paratur Ne%ara No&or ?0
?0 TaTa9u9un n 202012 12 TeTentntanan% % ,e,e!o!o&a&an n TaTata ta NaNas"s"a9 a9 iinanass nstansi ,e&erinta9=
nstansi ,e&erinta9= .
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2 2 Tentan% ,e!o&an Mana;e&en ,us"es&as=
Tentan% ,e!o&an Mana;e&en ,us"es&as= .
. ,e,eraratuturaran n "e"epapala la rrsisip p nanasisiononal al nono&o&or r 2 2 tata9u9un n 202011 te
tentntanan% % ,e,e!o!o&a&an n tatatta a nanas"s"a9 a9 iinanas s ((ereritita a NNe%e%araraa 5epubli" n!onesia Ta9un 201 no&or ?2)=
5epubli" n!onesia Ta9un 201 no&or ?2)= 6.
6. ,eratu,eraturan upati 4irebran upati 4irebon No&or 101 Ta9un on No&or 101 Ta9un 2017 Tentan2017 Tentan%% Tata
Tata Nas"a9 Nas"a9 inas inas !i !i /in%"up /in%"up ,e&erinta9 ,e&erinta9 aera9 aera9 !an!an ,e&erinta9 esa *abupaten 4irebon.
,e&erinta9 esa *abupaten 4irebon. MM-T-S*N
MM-T-S*N Me
Menenetatap"p"an an **,,-T-T-S-SN N **,,// NNS S **SSTTN N **--,,TTNN 45N TNTN8 TT NS* NS /N8*-N8N 45N TNTN8 TT NS* NS /N8*-N8N NS *STN *-,TN 45N.
NS *STN *-,TN 45N. *
*SSTT-- eennttuu" " !!aan n ssuussuunnaan n nnaass""aa9 9 ssuurraat t !!iinnaas s !!i i lliinn%%""uunn%%aan n iinnaass *ese9atan *abupaten 4irebon ter!iri atas
*ese9atan *abupaten 4irebon ter!iri atas a.
a. *ebi;a"an Surat *eputusan=*ebi;a"an Surat *eputusan= b.
b. Stan!ar perasional ,rose!urS,=Stan!ar perasional ,rose!urS,= $
$.. ,,ee!!oo&&aann,,aann!!uuaann== !
!.. **eerraann%%""a a $$uuaann== e.
e. a@tar Tili"=a@tar Tili"= ff.. Surat !aran=Surat !aran= g.
g. Surat iasa=Surat iasa= h.
h. Surat *eteran%an=Surat *eteran%an= i.
i. Surat ,erinta9=Surat ,erinta9= j.
j. Surat Bin=Surat Bin= k.
k. Surat ,erinta9 Tu%as=Surat ,erinta9 Tu%as= l.
l. Surat *uasa=Surat *uasa= m.
m. Surat -n!an%an=Surat -n!an%an= n.
n. Surat *eteran%an Mela"sana"an Tu%as=Surat *eteran%an Mela"sana"an Tu%as= o.
o. Surat ,an%%ilan=Surat ,an%%ilan= p.
p. Nota inas=Nota inas= q.
q. 5e"o&en!asi=5e"o&en!asi= rr.. Surat ,en%antar=Surat ,en%antar= s.
s. Notulen=Notulen= t.
t. a@tar a!ir=a@tar a!ir= u.
u. Surat ,er;an;ian=Surat ,er;an;ian=
.. /aporan asil *e%iatan=/aporan asil *e%iatan= :
:.. MMaannuuaal l MMuuttuu== x.
x. o"u&en ,eren$anaan /i&a Ta9un (5en$ana Strate%is)=o"u&en ,eren$anaan /i&a Ta9un (5en$ana Strate%is)= <.
<. 5en$ana -sulan *e%iatan (5-*)=5en$ana -sulan *e%iatan (5-*)= B.
B. 5e5en$n$anana ,a ,elela"a"sasananaan an *e*e%i%iatatan an (5(5,*,*)=)= aa
aa.. oo"u"u&e&en lan lain sin sesesuai uai "e"ebubututu9an9an.. *
*-- FFoorr&&aat t !!aan n bbeennttuu" " pprroo!!uu" " nnaass""aa9 9 !!iinnaas s sseebbaa%%aaii&&aannaa !i&a"su! pa!a !i"tu& *ST- ter$antu& !ala& la&piran !i&a"su! pa!a !i"tu& *ST- ter$antu& !ala& la&piran <an%
<an% &erupa"an &erupa"an ba%ian ba%ian <an% <an% ti!a" ti!a" terpisa9"an terpisa9"an !ari !ari suratsurat "eputusan ini=
"eputusan ini= *
*TT88 **eeppuuttuussaan n iinni i bbeellaa""u u ssee;;aa" " ttaann%%%%aal l !!iitteettaapp""aann> > aappaabbiilla a !!ii "
"e&e&u!u!iian an 9a9ari ri !i!itete&u&u"a"an n "e"e""eleliriruauan n a"a"an an !!ilila"a"u"u"anan perbai"an seba%ai&ana &estin<a.
perbai"an seba%ai&ana &estin<a.
itetap"an !i Su&ber itetap"an !i Su&ber
,a!a tan%%al 1 Januari 201? ,a!a tan%%al 1 Januari 201?
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Start Free Trial Cancel Anytime. ! ! / /MM,,55NN *,*,-T-T-S-SN N **,,/ / NNS *S *SSTTN *N *-,-,TTN N 4455NN N NMM55 TN88/ TN88/ 1 JN-5 201?1 JN-5 201? TNTN8 TNTN8 TNTN8 TT NS* NS /N8*-N8TNTN8 TT NS* NS /N8*-N8NN NS *STN *-,TN 45N NS *STN *-,TN 45N II.. KKEETTEENNTTUUAAN N UUMMUUMM 1.
1. PenPengguggunanaan kean kertartas;s;
a.
a. *e*ertrtas as <a<an% n% !i!i%u%una"na"an an ununtutu" " nanas"s"a9 a9 !i!inanas s a!a!alala9 a9 CCS S ?0?0 %ra&=
%ra&= b.
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Start Free Trial Cancel Anytime. " " && x 12 &&) && x 12 &&) e.
e. Mar%iMar%ins "ertas selns "ertas selain nas"a9 pi!ain nas"a9 pi!ato=ato= 1#
1# Top Top 20 && 20 && 2#
2# oottttoo&& 22 &&&& !#
!# //ee@@tt 330 0 &&&& "#
"# 55ii%%99tt 220 0 &&&& @.
@. MaMar%r%inins s "e"ertrtas as ununtutu" " nanas"s"a9 a9 pipi!a!ato to &e&en<n<esesuiui"a"an n u"u"ururanan "ertas !an u"uran 9uru@.
"ertas !an u"uran 9uru@. 2.
2. Pengetikan sarana adinistrasi dan k!unikasi "erkant!ran;Pengetikan sarana adinistrasi dan k!unikasi "erkant!ran;
a.
a. ,en,en%et%eti"ai"an n nas"nas"a9 a9 !in!inas as !al!ala& a& benbentu" !an tu" !an sussusunan pro!uunan pro!u"" 9u"u& <aitu Surat *eputusanS*> &en%%una"an ;enis 9uru@ 9u"u& <aitu Surat *eputusanS*> &en%%una"an ;enis 9uru@ bo
boo"o"&an &an olol! ! stst<l<le e !e!en%n%an an u"u"urauran n 12 12 !a!an n spspasi asi 1 1 atatau au 1>1> sesuai "ebutu9an=
sesuai "ebutu9an= b.
b. ,en%et,en%eti"an nas"a9 !inas sarana a!&insiti"an nas"a9 !inas sarana a!&insitrasi !an "o&uni"asrasi !an "o&uni"asii per
per"an"antortoran an &en&en%%u%%una"na"an an ;en;enis is 9uru9uru@ @ ariarial al u"uu"uran ran 12 12 ataatauu !isesuai"an "ebutu9an !an spasi 1 atau 1> sesuai "ebutu9an. !isesuai"an "ebutu9an !an spasi 1 atau 1> sesuai "ebutu9an. !.
!. Peneta"an #arna dan kua$itas kertas;Peneta"an #arna dan kua$itas kertas;
a.
a. Warna "ertWarna "ertas nas"a9 !inas a!alas nas"a9 !inas a!ala9 :arna puti9=a9 :arna puti9= b.
b. *ua*ualitlitas as "er"erta ta untuntu" u" nasnas"a9 !inas asli a!al"a9 !inas asli a!ala9 a9 CS ?0 CS ?0 %ra%ra&>&> se!an%"an untu" nas"a9 !inas <an% !i%an!a"an a!ala9 CS se!an%"an untu" nas"a9 !inas <an% !i%an!a"an a!ala9 CS 70 %ra&.
70 %ra&.
%.
%. K!K!" " susurarat;t;
a.
a. *o*op p nanas"s"a9 a9 !i!inanas s SaSatutuan an *e*er;r;a a ,e,eraran%n%"a"at t aaerera9 a9 (S(S*,*,)) &en%%una"an la&ban% !aera9 9ita& puti9 !ite&pat"an pa!a &en%%una"an la&ban% !aera9 9ita& puti9 !ite&pat"an pa!a ba%ian atas "iri "ertas> &e&uat sebutan ,e&erinta9 *abupaten ba%ian atas "iri "ertas> &e&uat sebutan ,e&erinta9 *abupaten 4irebon> na&a Satuan *er;a ,eran%"at aera9> ala&at> no&or 4irebon> na&a Satuan *er;a ,eran%"at aera9> ala&at> no&or telepon> no&or
telepon> no&or faksimile, website, email faksimile, website, email !an "o!e pos= !an "o!e pos= b.
b. *op nas"a9 *op nas"a9 !in!inas as -ni-nit t ,el,ela"sa"sana ana Te"Te"nis nis (-,(-,T) T) &en&en%%u%%una"na"anan la&ban% !aera9 9ita& puti9 !ite&pat"an pa!a ba%ian atas "iri la&ban% !aera9 9ita& puti9 !ite&pat"an pa!a ba%ian atas "iri "ertas
"ertas> > &e&uat sebutan &e&uat sebutan ,e&eri,e&erinta9 nta9 *abup*abupaten 4irebon> aten 4irebon> na&ana&a -,T> ala&at> no&or telepon> no&or
-,T> ala&at> no&or telepon> no&or faksimile, website, email faksimile, website, email !an !an "o!e pos=
"o!e pos= $.
$. Jenis 9urJenis 9uru@ pa!a "op !inu@ pa!a "op !inas untu" nas"aas untu" nas"a9 !inas !ala& be9 !inas !ala& bentu"ntu" !a
!an n susususunanan n prpro!o!u" u" 9u9u"u"u& & <a<aititu u SuSurarat t *e*epupututusasannS*S*>> &en%%una"an ;enis 9uru@ boo"&an ol! st<le !en%an u"uran 12 &en%%una"an ;enis 9uru@ boo"&an ol! st<le !en%an u"uran 12 !an spasi 1 atau 1> sesuai "ebutu9an. -"uran 9uru@ pa!a !an spasi 1 atau 1> sesuai "ebutu9an. -"uran 9uru@ pa!a na&a institusi a!ala9 12 !an !itebal"an=
na&a institusi a!ala9 12 !an !itebal"an= !
!.. JJeenniis s 99uurruu@ @ ppaa!!a a ""oop p !!iinnaas s ssaarraanna a aa!!&&iinnssiittrraassi i !!aann "o&uni"asi per"antoran &en%%una"an ;enis 9uru@ arial u"uran "o&uni"asi per"antoran &en%%una"an ;enis 9uru@ arial u"uran 12 atau !isesuai"an "ebutu9an !an spasi 1 atau 1> sesuai 12 atau !isesuai"an "ebutu9an !an spasi 1 atau 1> sesuai
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$ $ a.
a. ,enul,enulisan na&a isan na&a pe;abpe;abat untu" at untu" nas"a9 !nas"a9 !inas inas !ala& b!ala& bentu" !entu" !anan susunan pro!u" 9u"u& ti!a" &en%%una"an %elar> pan%"at !an susunan pro!u" 9u"u& ti!a" &en%%una"an %elar> pan%"at !an No&or n!u" ,e%a:ai (N,).
No&or n!u" ,e%a:ai (N,). b
b.. ,,eennuulliissaan n nnaa&&a a ppee;;aabbaat t uunnttuu" " nnasas""aa9 9 !!iinnas as ssararaanana a!&insitrasi !an "o&uni"asi per"antoran &en%%una"an %elar> a!&insitrasi !an "o&uni"asi per"antoran &en%%una"an %elar> pan%"at !an No&or n!u" ,e%a:ai (N,).
pan%"at !an No&or n!u" ,e%a:ai (N,).
&.
&. PenaPenandatndatangaanganan nanan naska' dska' dinasinas;;
a.
a. ,e,enanan!an!atatan%n%ananan an nanas"s"a9 a9 !i!inanas s !a!alala& & bebentntu" u" !a!an n susususunanann pro!u
pro!u" 9u"u& " 9u"u& !an nas"!an nas"a9 !inas a9 !inas !inas !inas sarana asarana a!&ins!&insitrasitrasii !an "o&uni"asi per"antoran !ila"u"an ole9 "epala S*,=
!an "o&uni"asi per"antoran !ila"u"an ole9 "epala S*,= b.
b. ,en,enan!aan!atantan%an%anan an nasnas"a9 "a9 !in!inas as !al!ala& a& benbentu" tu" !an !an sussusunanunan pro
pro!u" 9u"!u" 9u"u& !an nas"u& !an nas"a9 !inaa9 !inas s sarsarana a!&ana a!&insinsitritrasi !anasi !an "o
"o&un&uni"i"asasi i peper"r"anantotoran ran !i!ilala"u"u"a"an n olole9 e9 sese"r"retetararis is S*,S*, !ila"u"an sesuai !en%an "etentuan perun!an%an <an% berla"u= !ila"u"an sesuai !en%an "etentuan perun!an%an <an% berla"u= $.
$. ,e,enanan!an!atatan%n%ananan an nanas"s"a9 a9 !i!inanas s !a!alala& & bebentntu" u" !a!an n susususunanann pro
pro!u" 9u"!u" 9u"u& !an nas"u& !an nas"a9 !inaa9 !inas s sarsarana a!&ana a!&insinsitritrasi !anasi !an "o&uni"asi per"antoran !ila"u"an ole9 "epala -,T.
"o&uni"asi per"antoran !ila"u"an ole9 "epala -,T.
(.
(. PengPenggunagunaan tinan tinta nata naska' ska' dinadinas.s.
a.
a. TinTinta <anta <an% !i%% !i%una"una"an untan untu" nasu" nas"a9 !i"a9 !inas benas ber:arr:arna 9itna 9ita&=a&= b.
b. TiTintnta a <<anan% % !i!i%u%unana"a"an n ununtutu" " ppenenanan!a!atatan%n%ananan an !a!an n paparara@ @ nas"a9 !inas ber:arna biru tua=
nas"a9 !inas ber:arna biru tua= $.
$. TinTinta <anta <an% !i%% !i%una"una"an untan untu" "epu" "eperlerluan "euan "ea&ana&anan nasan nas"a9 !i"a9 !inasnas ber:arna &era9.
ber:arna &era9.
).
). Pen!Pen!!ra!ran n nasknaska' a' dinadinas.s.
a.
a. ,en,eno&oo&oran nasran nas"a9 !i"a9 !inas surnas surat <an% !iat <an% !itantan!at!atan%an%ani olani ole9 "epe9 "epalaala S*,
S*, !il!ila"u"a"u"an an oleole9 9 se"se"retretariaris s pa!pa!a a S*,S*, &as&asin%in%'&as'&asin%in% &e
&en%n%%u%unana"a"an n nono&o&or r > > "o"o!e !e "l"lasasi@i@i"i"asasi i !o!o"u"u&en &en !a!an n na&na&aa bi!
bi!an% an% S*,S*, terter"ai"ait t sessesuai uai !en!en%an %an subsubstastansi nsi nas"nas"a9 a9 !in!inasas surat=
surat= b.
b. ,eno&o,eno&oran nran nas"a9 as"a9 !inas !inas surat surat <an% <an% !itan!itan!atan%!atan%ani oani ole9 "le9 "epalaepala -,T !ila"u"an "epala -,T &asin%'&asin% &en%%una"an no&or -,T !ila"u"an "epala -,T &asin%'&asin% &en%%una"an no&or > "o!e "lasi@i"asi !o"unen !an na&a -,T ter"ait sesuai !en%an > "o!e "lasi@i"asi !o"unen !an na&a -,T ter"ait sesuai !en%an substansi nas"a9 !inas surat=
substansi nas"a9 !inas surat= $.
$. ,en,en%at%aturan nouran no&or na&or nas"as"a9 !ina9 !inas a!als a!ala9 seba9 seba%aa%ai beri beri"ui"utt 1)
1) NoNo&o&or r ururut ut teterbrbititn<n<a a nanas"s"a9 a9 !i!inanas s !i!itutulilis s !a!alala& & 3 3 (t(ti%i%a)a) an%"a=
an%"a= 2)
2) *o!e "lasi@i"asi *o!e "lasi@i"asi !ibuat ber!asar"an "o!e !ibuat ber!asar"an "o!e bu"u arsiparis <an%bu"u arsiparis <an% berla"u=
berla"u= 3)
3) Na&a S*,uniNa&a S*,unit-,T !i$antt-,T !i$antu&"an sesuai !en%an substansu&"an sesuai !en%an substansii nas"a9 !inas surat=
nas"a9 !inas surat=
*.
*. StStee"e"e$.$.
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% % peran%"at !aera9 a!ala9 $&=
peran%"at !aera9 a!ala9 $&= b.
b. -"-"ururan an %a%ariris s teten%n%a9 a9 lilin%n%"a"araran n teten%n%a9 a9 stste&e&pepel l ;a;ababatatan n !a!ann ste&pel peran%"at !aera9 a!ala9 3>? $&=
ste&pel peran%"at !aera9 a!ala9 3>? $&= $.
$. -"-"ururan an %a%ariris s teten%n%a9 a9 lilin%n%"a"araran n !a!alala& & stste&e&pepel l ;a;ababatatan n !a!ann peran%"at !aera9 a!ala9 2>7 $&=
peran%"at !aera9 a!ala9 2>7 $&= !.
!. JarJara" anta" antara 2 (!uaara 2 (!ua) %ari) %aris <an% tes <an% ter!ar!apat !apat !ala& lila& lin%"n%"araaran !ala&n !ala& &a"si&al 1 $&.
&a"si&al 1 $&. e.
e. StSte&e&pepel l uuntntu" u" S*S*, , beberirissi i nana&a &a ,e,e&e&eririntnta9 a9 *a*abubupapatetenn 4irebon> na&a S*, <an% bersan%"utan=
4irebon> na&a S*, <an% bersan%"utan= @.
@. SteSte&pe&pel untl untu" -,u" -,T berT berisi nisi na&a ,a&a ,e&ere&erintinta9 *aa9 *abupbupateaten 4irn 4ireboebon>n> na&a S*, !an na&a -,T <an% bersan%"utan.
na&a S*, !an na&a -,T <an% bersan%"utan.
II.
II. BENTUK DAN +ORMAT NASKAH DINASBENTUK DAN +ORMAT NASKAH DINAS 1.
1. KKe,e,ii-a-akkaan n S Suurarat Kt Kee"u"ututusasann;;
a
a.. ,,eenn%%eerrttiiaann
Surat "eputusan a!ala9 nas"a9 !inas !ala& bentu" !an susunan Surat "eputusan a!ala9 nas"a9 !inas !ala& bentu" !an susunan pro
pro!u" !u" 9u"9u"u& u& <an<an% % berbersi@si@at at penpenetaetapan pan "on"on"ri"rit> t> in!in!iDiiDi!ua!ual l !an!an @inal.
@inal. b
b.. 44iirrii''$$iirrii Mat
Materi eri berbersi@si@at at penpenetaetapanpan> > !it!ituan%uan%"an "an !al!ala& a& !i"!i"tu& tu& *S*ST-T->> *-
*- !an !an seteruseterusn<a> sn<a> penan!penan!atan%anatan%anann<a ann<a !apat !apat !i!e!i!ele%asile%asi"an"an "epa!a peran%"at !ala& stru"tur or%anisasi.
"epa!a peran%"at !ala& stru"tur or%anisasi. $.
$. SusuSusunan nan SurSurat at *ep*eputuutusan san terter!ir!iri i ataatass a)
a) ,e,e&b&bu"u"aanaan 1)
1) itituliulis ses selurluru9n<u9n<a !ea !en%an n%an 9ur9uru@ "au@ "apitpitalal
2#
2# itulis si&etris> !ileta""an !i ten%a9 &ar%insitulis si&etris> !ileta""an !i ten%a9 &ar%ins 3)
3) *e*ebibi;a;a"a"ann !i!ia:a:alali i !e!en%n%an "atan "ata a "e"epupututusasan> tann> tanpa !iapa !ia:a:alili "ata surat
"ata surat
"#
"# NNoo&&oorr !o!o""uu&&een n !!iibbuuaat t &&eenn%%ii""uutti i ""eetteennttuuaann seba%ai&ana ter$antu& !ala& "etentuan
seba%ai&ana ter$antu& !ala& "etentuan point ? !i atas.point ? !i atas.
$#
$# Jabatan Jabatan ;abatan ;abatan pe&buat pe&buat "eputusan "eputusan !itulis !itulis si&etris>si&etris> !ileta""an
!ileta""an !i!i tenten%a9 %a9 &ar&ar%in%ins s !an !an !ia!ia"9i"9iri ri !en!en%an %an tantan!a!a "o&a ( > )
"o&a ( > ) b)
b) *on*onsi!si!eraerann 1
1)) MMeennii&&bbaann%% i.
i. MeMe&u&uat at ururaiaian an sisin%n%"a"at t tetentntanan% % popo"o"o"'"'popo"o"o" " pipi"i"irarann <an%
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& & "apital !ia"9iri !en%an tan!a ba$a titi" !ua ( ) !an "apital !ia"9iri !en%an tan!a ba$a titi" !ua ( ) !an !ileta""an !i ba%ian "iri>
!ileta""an !i ba%ian "iri>
iiiii.i. **ononsisi!!ereran an &e&enini&b&banan% % !i!ia:a:alali i !e!en%n%an an pepenono&o&orarann &e
&en%n%%u%unana"a"an n 9u9ururu@ @ "e"e$i$il l !a!an n !i!i&u&ulalai i !e!en%n%an an "a"atata Eba9:a !en%an Eb 9uru@ "e$il
Eba9:a !en%an Eb 9uru@ "e$il 2
2)) MMeenn%%iinn%%aatt
ii.. MMee&&uuaat t !a!assaar r ""ee::eennaann%%aan n !!aan n ppeerraattuurraann p
peerruunn!!aann%%aan n <<aann% % &e&e&&eerriinnttaa99""aan n ppee&&bbuuaatt peraturansurat "eputusan tersebut
peraturansurat "eputusan tersebut
iiii.. **aatta a EEMMeenn%%iinn%%aatt !!iittuulliis s ssee;;aa;;aar r !!eenn%%aan n ""aattaa EMeni&ban%
EMeni&ban% ii
iii.i. ,e,erurun!n!anan%a%an !itn !itululis tais tanpnpa &ena &en%%%%ununa"a"an %aan %ariris &irs &irinin%% ( )
( )
iiDD.. ,,eerruunn!!aann%%aan n !!i i uurruutt""aan n sseessuuaai i 99iirraarr""i i ttaattaa perun!an%an !en%an ta9un a:al !isebut lebi9 !a9ulu. perun!an%an !en%an ta9un a:al !isebut lebi9 !a9ulu. 3)
3) iirarar"r"i pi pererunun!a!an%n%anan ii.. --nn!!aann%%''--nn!!aann%%
iii.i. ,,ereratatururan ,an ,enen%%%%ananti -ti -n!n!anan%'%'-n-n!a!an%n%==
iii.
iii. ,eraturan ,e&erinta9=,eraturan ,e&erinta9=
i
i.. ,eraturan ,resi!en=,eraturan ,resi!en=
.. *eputusan ,resi!en=*eputusan ,resi!en=
i.
i. ,eraturan Menteri *ese9atan=,eraturan Menteri *ese9atan=
ii.
ii. *eputusan Menteri "ese9atan=*eputusan Menteri "ese9atan=
iii.
iii. ,eraturan aera9=,eraturan aera9=
i'.
i'. ,eraturan 8ubernur=,eraturan 8ubernur= x.
x. ,eraturan upati.,eraturan upati.
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ii.. ii""ttuu& & EEMMMM--TT--SS**NN !!iittuulliis s ssii&&eettrriis s !!i i tteenn%%aa99 seluru9n<a !en%an 9uru@ "apital
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( ( per
peratuaturanransursurat at "ep"eputuutusan san <an<an% % !ir!iru&usu&us"an "an !al!ala&a& !i"tu&'!i"tu& &isaln<a !i"tu&'!i"tu& &isaln<a * *SSTT-- *- *- *T8 *T8 !st !st
iiii.. ii$$aannttuu&&""aan n ssaaaat t bbeerrllaa""uunn<<a a ssuurraat t ""eeppuuttuussaann>> per
perubauba9an> 9an> pe&bpe&bataatalanlan> > penpen$ab$abutautan n "et"etententuan> uan> !an!an peraturan lain<a.
peraturan lain<a. iii.
iii. Materi "ebi;a"an !apat !ibuat seba%ai la&piran suratMateri "ebi;a"an !apat !ibuat seba%ai la&piran surat "eputusan !an pa!a 9ala&an tera"9ir !itan!atan%ani "eputusan !an pa!a 9ala&an tera"9ir !itan!atan%ani ole9 pe;abat <an% &enetap"an surat "eputusan.
ole9 pe;abat <an% &enetap"an surat "eputusan.
)) **aa""ii
*a"i peraturansurat "eputusan &erupa"an ba%ian a"9ir *a"i peraturansurat "eputusan &erupa"an ba%ian a"9ir su
subsbstatansnsi i <a<an% n% &e&e&u&uat at pepenanan!n!a a tatan%n%an an pepenenerarapapann pe
peraratuturaransnsuraurat t "e"epupututusasan> n> pepen%n%un!un!an%an%an an peperatratururanan "eputusan <an% ter!iri !ari
"eputusan <an% ter!iri !ari
ii.. TeTe&p&pat at !a!an tn tanan%%%%al al pepenenettapapanan ii
ii.. NaNa&a ;&a ;ababatatan !an !iaia"9"9iriri !ei !en%n%an tan tanan!a "!a "o&o&aa iiiiii.. TTaann!!a a ttanan%%aan n ppee;;aabbaatt
iD
iD.. NaNa&a l&a lenen%"%"ap pap pe;e;ababat <at <anan% &e% &enanan!n!atatanan%a%anini D.
D. iitatan!n!atatan%an%anani i olole9 e9 "e"epapalala""oooor!r!ininatator or F*F*T, T, tatanpnpaa %elar !an N,
%elar !an N, D
Dii.. JJii""a a ssuurraat t ""eeppuuttuussaan n lleebbii9 9 !!aarri i ssaattu u 99aallaa&&aann>> 9ala&an "e!ua> "eti%a !an seterusn<a !itulis tanpa 9ala&an "e!ua> "eti%a !an seterusn<a !itulis tanpa &e
&en%n%%u%una"na"an an "o"op p susurarat> t> !a!an n pepenannan!a!atatan%n%anaanann "epala F*T, !ileta""an !i 9ala&an tera"9ir.
"epala F*T, !ileta""an !i 9ala&an tera"9ir. Di
Dii.i. /a/a&p&piriran ,an ,ereratatururananSSururat *at *epepututususanan /
/M,M,55NN **,,-T-T-S-SN N **,,// NNS S **SSTTN N **-,-,TTN 4N 455NN N
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Start Free Trial Cancel Anytime. ) ) ,M5NT *-,TN 45N ,M5NT *-,TN 45N NS *STN NS *STN
UPT PUSKESMAS CIREBON
UPT PUSKESMAS CIREBON
Jalan Sunan Muria No. 6 Telp (0231) 320273 Fax (0231) 320273 Jalan Sunan Muria No. 6 Telp (0231) 320273 Fax (0231) 320273
Website !in"es#$irebon."ab.%o.i! e&ail
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!i&ana !an ole9 siapa !ila"u"an. b.
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untu" u" "o"op p 9e9ea!a!inin% % ,u,us"s"eses&as &as &e&en%n%%u%unana"a"an n lolo%o %o ,e,e&!&!a a !a!ann lo%osi&bol ,us"es&as. 4onto9 penulisan "op 9ea!in% ,us"es&as lo%osi&bol ,us"es&as. 4onto9 penulisan "op 9ea!in% ,us"es&as a!ala9 seba%ai beri"ut
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!en%an "ali&at a"ti@ !en%an "o&posisi "ali&at antara lain a)
a) MMeenneettaapp""an an aa$$uuananppee!!oo&&ananllanan%%""a9a9''llaann%%""aa9 9 !!anan seterusn<a.
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!ala& pe&a9a&an lan%"a9'lan%"a9 !ala& S,. b#
b# ia%ra& alir !ala& S, :a;ib !i%una"an untu" "e%iatania%ra& alir !ala& S, :a;ib !i%una"an untu" "e%iatan <an%
<an% su!a9 su!a9 !iba"u"an !iba"u"an !ala& !ala& pe!o&an pe!o&an antara antara lainlain p
peenn<<eelleenn%%%%aarraaaan n pprroo%%rraa& & !!aan n ppeenn<<eelleenn%%%%aarraaaann pel
pela<aa<anannantintin!a"!a"an an "li"linisnis. . se!se!an%"an%"an an untuntu" u" tintin!a"!a"anan <an%
<an% ber"aitan ber"aitan !en%an !en%an @un%si @un%si &ana;e&en &ana;e&en ti!a" ti!a" :a;ib:a;ib !ibuat.
!ibuat. +#
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seba%ai beri"ut
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/aann%%""aa9 9 ""ee%%iiaattaann eennttuu" " ssii&&bbooll :al "e%iatan :al "e%iatan "9ir *e%iatan "9ir *e%iatan Si&bol *eputusan Si&bol *eputusan ,en%9ubun% ,en%9ubun% o"u&en o"u&en
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7)) --nniit t TTeerr""aaiitt er
erisi isi uniunit'ut'unit nit <an% <an% terter"ai"ait t !an !an ataatau u proprose!se!ur ur terter"ai"ait t !al!ala&a& proses "er;a tersebut.
proses "er;a tersebut. ?)
?) 5e5e"a"a&an &an iiststororis ,is ,ererububa9aa9ann
erisi $atatan peruba9an atau reDisi <an% ter;a!i pa!a
erisi $atatan peruba9an atau reDisi <an% ter;a!i pa!a S,.S,. A
A)) DDalaluauasi si ssi Si S,,
Daluasi S, !ila"sana"an sesuai "ebutu9an !an &ini&al
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eDaluasi S, &en%9asil"an re"o&en!asi antara lain a)
a) SS, &as, &asi9 ti9 tetetap bap bisisa !ipa !iperer%u%una"na"anan b)
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$)) ,,eerrbbaiai""aannrreeDDiissi i iissi i SS, , bbiissa a !!iilla"a"uu""an an ssebeba%a%iian an aattaauu seluru9n<a
seluru9n<a
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pela<anan "ese9atan $)
$) !a!an<a pn<a perueruba9ba9an oran or%ani%anisassasi atai atau "ebu "ebi;ai;a"an b"an baruaru !)
!) !!anan<a p<a pererububa9aa9an @n @asasililititasas e
e)) ,,eerraattuurraan n ""eeppalala a FF**TT, , tteettaap p bbeerrllaa""u u &e&ess""iippun un tteerr;;aa!!ii pen%%antian "epala F*T,.
pen%%antian "epala F*T,. 11
11)) DDalaluauasi si ,e,enenerarapapan Sn S,, a)
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Start Free Trial Cancel Anytime. 1! 1! Nama Nama Puskesmas Puskesmas
Tanda tangan Kepala Puskesmas Tanda tangan Kepala Puskesmas
Nama Kepala Nama Kepala Puskesmas Puskesmas NIP NIP 1. P
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1" 1" $.
$. SeSetitiap ap pepe!o!o&an&an p pan!an!uauan sen sebabai"i"n<n<a !ia !ilala"u"u"a"an eDn eDalaluasuasi &i &inini&i&alal se
seap 2'3 ta9un se"ali.ap 2'3 ta9un se"ali. !
!.. iilla a **ee&&eenntteerriiaan n **eessee99aattaan n tteellaa9 9 &&eenneerrbbiitt""aann ,e!
,e!o&ao&an,n,an!uan!uan an untuntu" u" suasuatu tu "e%"e%iatiatan an pelpela<ana<anan an tertertententu>tu> &a"a F*T, !ala& &e&buat pe!o&an pan!uan :a;ib &en%a$u &a"a F*T, !ala& &e&buat pe!o&an pan!uan :a;ib &en%a$u pa
pa!a !a pepe!o!o&an&an papan!n!uan uan <a<an% n% !i!iteterbrbitit"a"an n olole9 e9 *e*e&en&enteteririanan *ese9atan.
*ese9atan. e
e.. FFoorr&&aat bt baa""u su siissttee&&aa"a pe!o&an pan!uan <an% laBi& !i%una"an"a pe!o&an pan!uan <an% laBi& !i%una"an seba%ai beri"ut
seba%ai beri"ut 1)
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2)) **aatta a ppeenn%%aannttaarr 3
3)) ,,eenn!!aa99uulluuaann
)) 8 8aa&&bbaarraan -n -&&uu& F& F**T,T, )
) Ci Cisisi> Mi> Misisi> Fa> Falslsa@a@a9> Na9> Nililai !ai !an Tan Tu;u;uan uan F*F*T,T, 6)
6) C C StStruru"t"tur ur rr%a%aninisasasi si F*F*T,T, 7)
7) C C StStruru"t"tur ur rr%a%aninisasasi si -n-nit it *e*er;r;aa ?
?)) C C - -rraaiiaan Jn Jaabbaattaann A
A)) CC TTatata a ububunun%%an an **erer;;aa 10)
10) C C ,ola ,ola *eten*etena%aan a%aan !an *!an *uali@uali@i"asi i"asi ,erso,ersonilnil 11
11)) H H *e*e%i%iatatan an ririenentastasii 12
12)) H H ,e,ertrte&e&uauan n 5a5apapatt 13
13)) H H ,e,elalapoporarann a)
a) ,e,ellapapooraran n arariianan b)
b) ,e,elalapoporaran n uulalananann $)
$) ,e,ellapapooraran Tn Ta9a9ununanan @.
@. FForor&a&at ,t ,ee!o!o&a&an ,n ,eelala<a<ananan -n -ninit *t *erer;;aa 1
1)) **atata a pepen%n%ananttarar 2
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Start Free Trial Cancel Anytime. 1$ 1$ 1 1)) FFNNSS 2) 2) 5-5-NN8 /8 /NN8*8*-,-, 3) 3) T TTT / /**SSNN ) ) C C *-*-MMNTNTSS 9.
9. SiSiststee&a&atiti"a "a pepe!o!o&a&annppanan!u!uan an pepelala<a<ananan n ,u,us"s"eses&a&as s !a!apapatt !ib
!ibuat uat sessesuai uai !en!en%an %an &at&aterieriisisi i pe!pe!o&ao&anpnpan!uan!uan. an. ,e!,e!o&ao&ann pan!uan <an% 9arus !ibuat a!ala9 pe!o&anpan!uan &ini&al pan!uan <an% 9arus !ibuat a!ala9 pe!o&anpan!uan &ini&al <an% 9arus a!a !i F*T, <an%
<an% 9arus a!a !i F*T, <an% !ipers<arat"an seba%ai re%ulasi <an%!ipers<arat"an seba%ai re%ulasi <an% !
!ii&&iinntta a !!alala& a& eellee&e&en n ppeenniillaiaianan. . aa%%i i FF**TT, , <<anan% % tteellaa99 &
&eenn%%%%uunnaa""aann ee--ffiillee tteettaap p 99aarruus s &&ee&&ppuunn<<aaii hardcopy hardcopy pe!
pe!o&ao&anpnpan!uan!uan an <an<an% % !i"!i"eloelola la oleole99 & & a"ra"re!ie!itastasi i F*TF*T, , ataatauu ba%ian Tata -sa9a F*T,.
ba%ian Tata -sa9a F*T,.
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*eraran%n%"a "a a$a$uauan n !i!isussusun un ununtutu" " prpro%ro%ra& a& atatau au "e"e%i%iatatan an <a<an% n% a"a"anan !ila"u"
!ila"u"an an ole9 F*T,. ole9 F*T,. ,ro%r,ro%ra&"e%a&"e%iatan <an% iatan <an% !ibuat "eran%"a a$uan !ibuat "eran%"a a$uan a!ala9a!ala9 sesuai !en
sesuai !en%an stan%an stan!ar a"re!i!ar a"re!itasi. tasi. ala& &enala& &en<usun "e<usun "e%iatan a%iatan a9rus ;elas9rus ;elas tu;uan !an "e%iatan'"e%iatan <an% a"an !ila"u"an !ala& &en$apai tu;uan tu;uan !an "e%iatan'"e%iatan <an% a"an !ila"u"an !ala& &en$apai tu;uan u&u& !an tu;uan "9usus <an% &erupa"an tu;uan !ari tiap'tiap "e%iatan u&u& !an tu;uan "9usus <an% &erupa"an tu;uan !ari tiap'tiap "e%iatan <an%
<an% a"an a"an !ila"u"an. !ila"u"an. ala& ala& "eran%"a "eran%"a a$uan a$uan 9arus 9arus !i;elas"an !i;elas"an ba%ai&anaba%ai&ana $a
$ara ra &e&elala"s"saanana"a"an n "e"e%i%iatatan an a%a%ar ar ttu;u;uauan n teter$r$apapai ai !e!en%n%an an !e!enn%a%ann pen;a!:alan <an% ;elas !an eDaluasi serta pelaporan.
pen;a!:alan <an% ;elas !an eDaluasi serta pelaporan.
,enulisan !ia:ali !en%an *, !inas F*T,> ;u!ul !an no&or ,enulisan !ia:ali !en%an *, !inas F*T,> ;u!ul !an no&or "e
"eranran%"%"a a a$a$uanuan. . SiSistste&e&atati"i"aa@o@or&r&at at pepenulnulisisan an "e"eranran%"%"a a a$a$uanuan seba%ai beri"ut
seba%ai beri"ut a
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