STANDAR OPERASIONAL PROSEDUR PENGELOLAAN KEGIATAN MULTILATERAL. Nomor: SOP /KS 01 04/HHK 3.2. bat an BADAN TENAGA NUKLIR NASIONAL 2020

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BADAN TENAGA NUKLIR NASIONAL 2020

bat an

STANDAR OPERASIONAL PROSEDUR PENGELOLAAN KEGIATAN MULTILATERAL

Nomor: SOP 076.002/KS 01 04/HHK 3.2

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TANGGAL TANDA TANGAN

PH. Sekretaris Utama Kepala Biro Sumber Daya Manusia dan Organisasi

Kepala Biro Hukum Hubungan Masyarakat dan Kerja Sama

Penyusun Program

Kelembagaan dan Kerja sama

Pranata Humas Ahli Muda

JABATAN

Ir. Falcon/Margono

Sutarto, MM

2. Dr. Ir. Sudi Ariyanto, M.Eng.

1. Drs. Raden Heru Umbara.

2. Dirgahary Tamara,

S.Si. M.Si

1. Ros Intan

Purbasari, ST., M.T.

NAMA

Disahkan Diperiksa

Disiapkan

TINDAKAN

LEMBAR PENGESAHAN

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Kepala Pusat Standardisasi dan Mutu Nuklir Kepala Pusat Pendidikan dan Pelatihan Inspektur

Kepala Pusat Pendayagunaan Informatika dan Kawasan Strategis Nuklir Kepala Pusat Diseminasi dan Kemitraan

Kepala Pusat Reaktor Serba Guna

Kepala Pusat Teknologi Radioisotop dan Radiofarmaka Kepala Pusat Rekayasa Fasilitas Nuklir

Kepala Pusat Teknologi Limbah Radioaktif Kepala Pusat Kajian Sistem Energi Nuklir

Kepala Pusat Teknologi dan Keselamatan Reaktor Nuklir Kepala Pusat Teknologi Bahan Bakar Nuklir

Kepala Pusat Teknologi Bahan Galian Nuklir Kepala Pusat Aplikasi Isotop dan Radiasi

Kepala Pusat Teknologi Keselamatan dan Metrologl Radiasi Kepala Pusat Sains dan Teknologi Akselerator

Kepala Pusat Sains dan Teknologi Nuklir Terapan Kepala Pusat Sains dan Teknologi Bahan Maju

Kepala Biro Hukum, Hubungan Masyarakat, dan Kerja Sama Kepala Biro Umum

<epala Biro Sumber Daya Manusia dan Organisasi

<epala Biro Perencanaan

JABATAN

22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 8 5 4 3 2 1 NOMOR SALINAN

DISTRIBUSI

DAFTAR DISTRIBUSI

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Sub Koordinator Unit Jaminan Mutu Pusat Pendidikan dan Pelatihan Ketua Tim Jaminan Mutu Inspektorat

Sub Koordinator Unit Jaminan Mutu Pusat Pendayagunaan Informatika dan

Kawasan Strategis Nuklir

Sub Koordinator Unit Jaminan Mutu Pusat Diseminasi dan Kemitraan Sub Koordinator Unit Jaminan Mutu Pusat Reaktor Serba Guna Sub Koordinator Unit Jaminan Mutu Pusat Teknologi Radioisotop dan Radiofarmaka

Sub Koordinator Unit Jaminan Mutu Pusat Rekayasa Fasilitas Nuklir Sub Koordinator Unit Jaminan Mutu Pusat Teknologi Limbah Radioaktif Sub Koordinator Unit Jaminan Mutu Pusat Kajian Sistem Energi Nuklir Sub Koordinator Unit Jaminan Mutu Pusat Teknologi dan Keselamatan Reaktor Nuklir

Sub Koordinator Unit Jaminan Mutu Pusat Teknologi Bahan Bakar Nuklir Sub Koordinator Unit Jaminan Mutu Pusat Teknologi Bahan Galian Nuklir Sub Koordinator Unit Jaminan Mutu Pusat Aplikasi Isotop dan Radiasi Sub Koordinator Unit Jaminan Mutu Pusat Teknologi Keselamatan dan Metrologi Radiasi

Sub Koordinator Unit Jaminan Mutu Pusat Sains dan Teknologi Akselerator Sub Koordinator Unit Jaminan Mutu Pusat Sains dan Teknologi Nuklir Terapan Sub Koordinator Unit Jaminan Mutu Pusat Sains dan Teknologi Bahan Maju Ketua Tim Jaminan Mutu Biro Hukum, Hubungan Masyarakat, dan Kerja Sama

Ketua Tim Jaminan Mutu Biro Umum

Ketua Tim Jaminan Mutu Biro Sumber Daya Manusia dan Organisasi Ketua Tim Jaminan Mutu Biro Perencanaan

Ketua Sekolah Tinggi Teknologi Nuklir

JABATAN

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DISTRIBUSI

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Koordinator Bagian Organisasi dan Tata Laksana

Ketua Tim Jaminan Mutu Sekoiah Tinggi Teknologi Nuklir Koordinator Jaminan Mutu Pusat Standardisasi dan Mutu Nuklir

JABATAN

Master

46 45 NOMOR SALINAN

DISTRIBUSI

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2 3 6 7 7 7 7 8 9 11 12 14 15 16 TUJUAN

RUANGUNGKUP TANGGUNG JAWAB

DEFINISI REFERENSI SOP

6.1.SOP Penawaran Kegiatan

6.2.SOP Pencalonan Peserta Kegiatan

LAMPIRAN

Lampiran 1 : Kriteria Pengisian Formulir Pencalonan Lampiran 2 : Persyaratan Pencalonan Kegiatan

Lampiran 3 : Formulir IAEA Form A {Participation Form), Form B {Form for Submission of a Paper), dan Form C {Grant Application

Form) 17 Lampiran 4 : Formulir IAEA Nomination for Training Course 23 Lampiran 5 : Formulir IAEA Nomination for Meeting/Workshop and

National Consultant 27

DAFTAR ISi

LEMBAR PENGESAHAN DAFTAR DISTRIBUSI DAFTAR ISI

1.

2.

3.

4.

5.

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4. DEFINISI

Dalam SOP ini yang dimaksud dengan:

4.1. Kegiatan Multilateral adalah kegiatan berupa meeting, workshop, training course, seminar, conference, dan symposium yang diikuti oleh peserta dari beberapa 1.TUJUAN

Standar Operasional Prosedur (SOP) ini dibuat untuk mengatur tata cara pengelolaan kegiatan Multilateral agar berjalan dengan lancar, efektif, efisien, dan terdokumentasi.

2.RUANG LINGKUP

Ruang lingkup SOP ini berlaku untuk seluruh unit kerja di BATAN yang kegiatannya meliputi penawaran kegiatan multilateral dan pencalonan peserta kegiatan multilateral.

3.TANGGUNG JAWAB

3.1.Kepala BATAN bertanggung jawab dalam hal kebenaran informasi tawaran kegiatan dari IAEA/PTRI Wina/lembaga penyelenggara lain dan pemberian

arahan.

3.2.Sestama/Deputi terkait bertanggung jawab dalam hal pemberian arahan pencalonan kepada unit kerja terkait, khusus kegiatan meeting, seminar dan

conference.

3.3.Kepala BHHK bertanggung jawab dalam hal:

3.3.1.kebenaran distribusi tawaran kegiatan dari IAEA/PTRI Wina/lembaga penyelenggara lain;

3.3.2.kesesuaian penyeleksian calon peserta kegiatan yang diusulkan;

3.3.3.ketepatan pemehksaan kelengkapan dan kesesuaian berkas pencalonan;

dan

3.3.4.ketepatan waktu pemrosesan pencalonan ke lAEA/lembaga penyelenggara

lain.

3.4.Kepala unit kerja terkait bertanggung jawab dalam hal kesesuaian dan kelengkapan berkas pencalonan peserta kegiatan, serta ketepatan waktu pengiriman pencalonan.

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5. REFERENSI

5.1. Peraturan Menteri Negara Pendayagunaan Aparatur Negara dan Reformasi Birokrasi Nomor 35 Tahun 2012 tentang Pedoman Penyusunan Standar Operasional Prosedur (SOP) Administrasi Pemerintahan.

negara, baik yang diselenggarakan oleh IAEA maupun lembaga penyelenggara lain, yang bukan bersifat G to G.

4.2.Training course adalah bentuk pelatihan untuk memperoleh pengetahuan, keterampilan dan kompetensi, dan bertujuan untuk meningkatkan kemampuan

peserta.

4.3.Meeting adalah kegiatan pertemuan antar sekelompok orang yang bersifat formal dengan tujuan untuk membahas perencanaan, penetapan kebijakan, dan pengambilan keputusan.

4.4.Workshop adalah kegiatan yang mempertemukan sekelompok orang dengan latar belakang keahlian, minat, atau profesi yang sama untuk berdiskusi pada suatu isu spesifik tertentu, dan lebih menekankan pada pelatihan.

4.5.Seminar adalah suatu kegiatan yang diselenggarakan guna menyampaikan pemikiran ilmiah dalam bentuk presentasi, dengan tujuan untuk mendiskusikan suatu masalah dan mencari solusi terbaik.

4.6.Conference adalah suatu pertemuan atau perundingan yang memungkinkan bagi seluruh orang yang hadir untuk memahami maupun menyetujui suatu diskursus.

4.7.Symposium adalah penyampaian rangkaian pidato pendek di hadapan peserta, dimana terdapat beberapa pembicara dan isu yang diangkat pun selaras antara satu dengan yang lain. Namun bisa juga satu topik besar kemudian dibagi menjadi beberapa sudut pandang yang akan dikupas satu persatu oleh pembicara.

4.8.Berkas pencalonan adalah formulir pencalonan mengikuti kegiatan beserta kelengkapannya.

4.9.International Atomic Energy Agency (IAEA) adalah organisasi intemasional otonom di dalam sistem Perserikatan Bangsa-Bangsa (PBB) yang terkait dengan promosi pemanfaatan energi nuklir untuk tujuan damai.

4.10.Perwakilan Tetap Republik Indonesia (PTRI Wina) adalah perwakilan Pemerintah Indonesia di Wina.

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SOP

Diagram alir SOP Pengelolaan Kegiatan Multilateral dapat dillhat pada tabel berlkut ini terdiri dari:

6.1.SOP Penawaran Kegiatan; dan 6.2.SOP Pencalonan Peserta Kegiatan

5.2.Peraturan Kepala BATAN Nomor 12 Tahun 2013 tenlang Pedoman Penyusunan dan Pengendalian Standar Operasional Prosedur BATAN.

5.3.Peraturan Kepala BATAN Nomor 14 Tahun 2013 tentang Organisasi dan Tata Kerja Badan Tenaga Nuklir Nasional sebagaimana telah diubah dengan Peraturan Kepala BATAN Nomor 16 Tahun 2014.

5.4.Peraturan Kepala BATAN Nomor 21 Tahun 2014 tentang Rincian Tugas Unit Kerja di Badan Tenaga Nuklir Nasional.

5.5.Statute IAEA yang sudah diamandemen tanggal 28 Desember 1989.

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1. Note Verbal IAEA

2. Formulir pendaftaran peserta

3. Letter of Invitation dari penyelenggara 4. Rincian kegiatan multilateral

5. Laporan hasil pelaksanaan kegiatan Pencatatan dan Pendataan:

. ATK

• Komputer, Scanner, Printer Peralatan dan Perlengkapan:

• memahami prospektus kegiatan dan persyaratan dari IAEA maupun lembaga penyelenggara lain

• memahami persyaratan BATAN untuk mengikuti kegiatan di luar negeri

Kualifikasi Pelaksana:

• Calon peserta harus sesuai dengan kompetensi dan persyaratan

• Dalam memproses pencalonan agar memperhatikan batas akhir pencalonan di lembaga penyelenggara dan batas waktu yang ditentukan BHHK

Peringatan:

SOP Tata Cara Permohonan Izin dan Biaya Perjalanan Dinas Luar Negeri

Keterkaitan:

Peraturan Kepala BATAN Nomor 21 Tahun 2014 tentang Rincian Tugas Unit Kerja di Badan Tenaga Nuklir Nasionai

Dasar Hukum:

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Formulir pencalonan sesuai dengan lampiran 3,4, dan 5

• Training Course dan Workshop dapat ditawarkan langsung ke unit kerja dan instansi terkait

• Bila surat ditujukan kepada NLO/Kepala BHHK dapat langsung diproses lanjut Khusus kegiatan meet/ng/seminar dan conference

Keterangan

• Tawaran kegiatan dari lembaga penyelenggara

• Formulir pencalonan

• Nota Dinas/Surat Dinas

• Disposisi

Output

1 hari

5 hari

1 hari 1 hari

Waktu

> Nota Dinas

• Surat Dinas

• Formulir pencalonan

• Disposisi

Kelengkapan

Mutu Baku

b

c

Unit Kerja teriiaitf Instansi terkait Kepala

BHHK Sestama/

Deputi terkait Kepala

BATAN

Pelaksana

Menerima tawaran kegiatan Menerima disposisi pencalonan dan menyampaikan tawaran Memberi disposisi pencalonan Menerima informasi tawaran kegiatan dari lembaga penyelenggara

PROSES

6.1.4.

6.1.3.

6.1.2.

6.1.1.

NO

6.1. SOP Penawaran Kegiatan

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Seleksi yang dilakukan meliputi:

• kesesuaian kompetensi dengan kegiaian yang akan diikuti

• kelengkapan berkas

Keterangan

• Hasil seleksi

• Surat Dinas pencalonan peserta kegiatan

• Nota Dinas/Surat Dinas pemberitahuan calon peserta yang tidak lolos seleksi

• Berkas calon peserta kegiatan yang lolos seleksi

• Formulir pencalonan yang sudah diisi dan berkas kelengkapan

Output

2hari 2hari

5hari Waktu

• Surat Dinas pencalonan peserta kegiatan

• Berkas calon peserta kegiatan yang lolos seleksi

• Formulir pencalonan yang sudati diisi dan berkas kelengkapan

• Tawaran kegiatan dari lembaga penyelenggara lain

• Formulir pencalonan Kelengkapan

Mutu Baku

-fcl1

lAEAflembaga penyelenggara

lain

Lolos seleksi

r

OlOS '

si /

Ka. BHHK

Tidak I

selel

c p-

Unit Kerja/

Instansi terkait

Pelaksana

Melakukan seleksi terhadap berkas pencalonan peserta kegiatan dan mengirimkan hasil seleksi

• Memproses pencalonan yang lolos seleksi

• Mengirimkan berkas pencalonan peserta kegiatan

Menyeleksi pencalonan peserta kegiatan yang diusulkan

Menyiapkan dan mengirim pencalonan peserta kegiatan

PROSES

6.2.4.

6.2.3.

6.2.2.

6.2.1.

NO

6.2. SOP Pencalonan Peserta Kegiatan

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Untuk instansi terkait pengurusan dokumen

dilakukan di instansi masing2 Untuk proses keberangkatan dan pelaporan kegiatan bagi peserta yang lolos seleksi mengikuti SOP Tata Cara Permohonan Izin dan Biaya Perjalanan Dinas Luar Negeri Menerima hasil seleksi

•Menerima hasil seleksi dari peserta

V

kegiatan

•Menyampaikan hasil seleksi

Keterangan Halaman

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Kriteria Pengisian Formulir Pencalonan Persyaratan Pencalonan Kegiatan

Formulir IAEA Form A {Participation Form), Form B (Form for Submission of a Paper), dan Form C {Grant Application Form) Formulir IAEA Nomination for Training Course

Formulir IAEA Nomination for Meeting/Workshop and National Consultant

7. LAMPIRAN Lampiran 1 Lampiran 2 Lampiran 3

Lampiran 4 Lampiran 5

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Untuk kegiatan IAEA, formulir yang digunakan adalah:

•Form A (Participation Form), B (Form for Submission of a Paper), dan C (Grant Application Form) {lampiran 3).

•Untuk kegiatan yang membutuhkan biaya dari proyek kerja sama teknis, peserta mengisi formulir lain yaitu untuk:

1)training course, menggunakan formulir "Nomination for TC Training Course"

{lampiran 4);

2)workshop dan meeting, menggunakan formulir "Nomination for TC Meeting"

(lampiran 5).

Kriteria Pengisian Formulir Pencalonan

Lampiran 1 Halaman :15dari30

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1.Tidak sedang dicalonkan untuk mengikuti kegiatan lain yang waktunya bersamaan.

2.Tidak sedang berstatus CPNS.

3.Untuk training course, persyaratan yang hams dipenuhi adalah sebagai berikut:

a.Batas maksimum usia calon yang diusulkan adalah 52 tahun;

b.Apabila sertifikat bahasa Inggris dipersyaratkan oleh lembaga penyelenggara, maka mengikuti ketentuan Pusdiklat BATAN.

4.Untuk meeting, persyaratan yang harus dipenuhi adalah sebagai berikut:

a.Pegawai memiliki masa kerja lebih dari 5 tahun;

b.melengkapi CV terkait pengalaman dalam bidang meeting yang akan diikuti; dan c.mempunyai pengalaman pada bidang terkait kegiatan yang akan diikuti minimal 5

tahun atau yang telah mendapatkan penunjukan dari pimpinan.

Persyaratan Pencalonan Kegiatan

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Representing following Member State/non-Member

State/entity or invited organization:

Nationality:

Tel. (Fax):

First name(s): (e.g. John)

Family name: (e.g. Smith)

^adline for receipt by IAEA through official channels: **

Technical Meeting / Training Course IAEA Headquarters, Vienna, Austria Date

To be completed by the participant and sent to the competent national authority (e.g. Ministry of Foreign Affairs, Permanent Mission to the IAEA, or National Atomic Energy Authority) of his/her country for subsequent transmission to the International Atomic Energy Agency (IAEA) either by email to: Official.Maiiiijliaea.org or by fax to : +43 1 26007 (no hard copies needed).

Participants who are members of an invited organization can submit this form to their organization for subsequent transmission to the IAEA.

Participation Form

Lampiran 3

Form A

EVT^

IAEA

lnla.naiion.1 Alwnk E^rgy Antncy AiomsforPeacrandDevtlopmeia

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No No

Yes

ter as a poster?

Title:

Would you prefer to present your pa

Do you intend to submit a paper?

If/as applicable:

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Email:

Tel. (Fax):

Mailing address:

Mr/Ms:

City/Country

Family name and first name(s) of author presenting

the paper: e.g. Smith, John

Scientific establishment(s) in which the work has been carried out

3.

2.

1.

Family name(s) and first name(s) of all author(s):

e.g. Smith, John

If applicable: Abstract ID in IAEA-INDICO:

Title of the paper:

Deadline for receipt by IAEA through official channels: -

Form for Submission of a Paper

Technical Meeting / Training Course IAEA Headquarters, Vienna, Austria Date

To be completed by the participant and sent to the competent national authority (e.g. Ministry of Foreign Affairs, Permanent Mission to the IAEA, or National Atomic Energy Authority) of his/her country for subsequent transmission to the International Atomic Energy Agency (IAEA) either by email to: [email protected] or by fax to:

+43 1 26007 (no hard copies needed).

Participants who are members of an invited organization can submit this form to their organization for subsequent transmission to the IAEA.

tu for Peace and Development

Form B Halaman : 19 darl 30

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Signature of main author:

Furthermore, I herewith declare:

that the material submitted to the IAEA is original, except for such excerpts from copyrighted works as may be included with the permission of the copyright holders thereof, has been written by the stated authors, has not been published before, and is not under consideration for publication by another entity;

that any permissions and rights to publish required for third-party content, including but not limited to figures and tables, have been obtained, that all published material is correctly referenced; and

that the material submitted to the IAEA does not contain any libellous or other unlawful statements and does not contain any materials that violate any personal or proprietary rights of any person or

entity.

I hereby agree to assign to the International Atomic Energy Agency (IAEA):

the copyright; or

the non-exclusive, worldwide, free-of-charge licence (this option is only for those authors whose

parent institution does not allow them to transfer the copyright for work carried out in that institution) granting the IAEA world rights for the use of the aforementioned material in this and any future editions of the publication, in all languages, and in all formats available now, or to be developed in the

future (digital formats, hard copy etc.).

Please note: If granting the licence mentioned above, please supply any copyright acknowledgement

text required.

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Years worked from to

Type of work

Title of your position Name and place of employer/

2. Recent employment record (starting with your present post):

Years attended from to Diploma or Degree

Field of study Name and place of institution

1. Education (post-secondary):

Nationality:

Email:

Fax:

Tel.:

Mr/Ms:

Date of birth fyyyy/mm/dd):

Mailing address:

First name(s): (e.g. John) Family name: (e.g. Smith)

Deadline for receipt by IAEA through official channels: -

submit this form to their organization for subsequent Participants who are members of an invited organizatio

transmission to the IAEA.

Technical Meeting / Training Course IAEA Headquarters, Vienna, Austria Date

To be completed by the participant and sent to the competent national authority {e.g. Ministry of Foreign Affairs, Permanent Mission to the IAEA, or National Atomic Energy Authority) of his/her country for subsequent transmission to the International Atomic Energy Agency (IAEA) either by email to: Official. Mai I(5jiaea.org or by fax to:

+43126007 (no hard copies needed).

Grant Application Form IAEA

Halaman : 21 darl 30 Tgl. Berlaku :

No.Revisi/

Terbitan '1

„ I SOP 076.002/

iromor KS 01 04/HHK 32

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Name, signature and stamp of Ministry of Foreign Affairs, Permanent Mission to the IAEA or National Atomic Energy Authority 4. Institute's/Member State's programme in field of event:

Date: _____„_„_ Signature of applicant:

3. Description of work performed over the last three years:

Halaman : 22 dari 30

Tgl. Berlaku :

No. Revlsl/

Terbitan :0M

Mnmnr : SOP 076.002/

Nomor KS 01 04/HHK 32

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Speak, read and write nearly as well as mother tongue

gage freely in discussions, read and w re complex material

mted conversation, reading of vspapers, routine correspondence WORKING KNOWLEDGE

(W) LIMITED (L)

Language:

3. LANGUAGE SKILLS

Telephones (including country/city codes):

Preferred Number:

Alternate Number 1:

Alternate Number 2:

Preferred email:

Alternate email:

2. CONTACT DETAILS

Date of Expiry: YYYY-MM-DD Date of birth: YYYY-MM-DD

Date of issue: YYYY-MM-DD Middle name (if any):

2nd nationality (if any):

Gender: B Female

1. PERSONAL INFORMATION (As per passport)

organized under TC project The Government (nominating authority) of

Nominates the person indicated below for the followi Event title:

Location:

Date(s): YYYY-MM-DD - YYYY-MM-DD

NOMINATION FOR TC TRAINING COURSE

Lam pi ran 4 Halaman : 23 dari 30

Tgl. Berlaku :

No. Revisl/

Terbltan :0M

„ : SOP 076.002/

KS 01 04/HHK 3.2

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YYYY/MM ^ YYYY/MM No

YYYY/MM - YYYY/MM No

YYYY/MM - YYYY/MM

Title of Position:

Job Function:

City, Country:

Employer:

Stan date - End date Currentjob: B Yes f Description of Duties:

Title of Position:

Job Function:

City, Country:

Employer:

Start date - End date Current job: Yes C Description of Duties:

Title of Position:

Job Function:

City, Country:

Employer:

Start date - End date

Current job: D Yes Q No

5. WORK EXPERIENCE

YYYY/MM - YYYY/MM YYYY/MM - YYYY/MM YYYY/MM - YYYY/MM

Field of study:

Education level:

City, Country:

Institution:

Start date - End date Field of study:

Education level:

City, Country:

Institution:

Education level:

City, Country:

Institution:

4. EDUCATION

Halaman : 24 darl 30 Tgl. Berlaku :

No. Revisi/ _ ,, Terbitan :Q/1

„ : SOP 076.0021 Nomor KS Q1 04/HHK 32

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Past work done by the ;

7. DESCRIPTION OF WORK

eillance Remarks:

0No

Please provide:

•A medical certificate or personal declaration of health fitness to work with it

•Information on your training in radiological protection;

The dose records of the past five years (if available).

Please provide the dose records for the past five years.

^ountry?

eiliance programme ir Are you covered under a radiatio

events with a duration exceeding one month;

all candidates over the age of 65 regardless of the i

A medical certificate of good health signed by a registered medical practitioner dated not more than four months prior to the event must be submitted for:

If you have a physical disability or medical condition which might limit your ability to perform your assignment, pies indicate the limitations below:

;s and able physically and mentally to carry out any rt I declare thai I am in good health, free fror

duties away from home.

EgEg No

6. HEALTH AND RADIATION

Halaman : 25 dari 30

Tgl. Berlaku :

No. Revisl/

Terbitan :0'1

Nomor :^P01^^cj.2

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DATE: YYYY-MM-DD DATE: YYYY-MM-DD

SIGNATURE OF NLO

SIGNATURE OF COUNTERPART

le to receive during the training a salary ts in his/her home country;

ith his/her status as a participant in an ivities;

which would

10. COUNTRY APPROVAL

The nominating authority gives the following assurances:

•All information supplied in this form is complete and correct, and the applicant is proficient in the training language;

•Should the candidate's language qualification prove to be insufficient or should the candidate's state of health not correspond to the examining physician's statement, the nominating authority will accept the responsibility for the consequences and any costs arising therefrom;

•It is noted that the sponsoring organization(s), host country(ies) and host institution(s) do not accept liability for the payment of any costs or compensation arising from damage to or loss of personal property, or from illness, injury, disability or death of a participant while he/she is travelling to and from or attending the training course and it, the nominating authority, undertakes the responsibility for such coverage;

•The position of the nominee will be retained for him/her and he/she will con and related emoluments to enable him/her to meet his/her financial commitn

•If selected, the nominee will conduct himself/herself in a manner compatibl^

IAEA event and will refrain from engaging in any political and commercial

•No facts are known to the nominating authority regarding the reliability and character of the m obstruct giving him/her access to nuclear installations or institutions where ionizing radiation i

;eived by the candidate at the • oing to make use of the train

9. OBJECTIVES FROM THE GOVERNMENT'S POINT OF VIEW

any IAEA activity?: ? Yes

een or will you be involved ir :e list each activity below:

8. PREVIOUS PARTICIPATION IN IAEA ACTIVITIES

Halaman : 26 dari 30 Tgl. Berlaku :

No.RevisI/

Tcrbitan -0'1

„„_.. : SOP 076.002/

nomor KS 01 04/HHK 3.2

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Speak, read and write nearly as well as mother tongue

Engage freely in discussions, read and write more complex material

Limited conversation, reading of newspapers, routine correspondence

FLUENT (F) WORKING KNOWLEDGE (W) LIMITED (L) Description:

Proficiency:

Language:

Mother tongue:

11. LANGUAGE SKILLS

irport/town nearest to residence:

referred email:

Itemate email:

referred Number:

Itemate Number 1:

Itemate Number 2:

elephones (including country/city codes):

ountry:

ity:

Postal Code:

nstitute address:

Institute name:

2. CONTACT DETAILS

Place of issue:

Date of Expiry: YYYY-MM-DD Date of issue: YYYY-MM-DD Passport No.:

2nd nationality (if any):

Nationality:

Pace of birth:

Date of birth: YYYY-MM-DD First name:

Middle name (if any):

Last name:

Gender: P Female Q Male

2. PERSONAL INFORMATION (As per passport)

The Government (nominating authority) of

Nominates the person indicated below for the following event organized under TC project:

Event title:

Location:

Date(s): YYYY-MM-DD - YYYY-MM-DD

NOMINATION FOR TC MEETING

Lampiran 5 Halaman : 27 dari 30

Tgl. Berlaku : No.Rsvisi/ ....

Terbilan -0'1

Nomor : S0P076002/

SOP PENGELOLAAN KEGIATAN MULTILATERAL

BAD AN TENAGA NUKLIR NASIONAL

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YYYY/MM - YYYY/MM No

YYYY/MM - YYYY/MM

Job Function:

City, Country:

Employer:

Start date - End date Currentjob: ? Yes C Description of Duties:

Title of Position:

Job Function:

City, Country:

Employer:

Start date - End date Currentjob: ? Yes C Description of Duties:

Title of Position:

Job Function:

City, Country:

Employer:

Currentjob: ? Yes ? No

13. WORK EXPERIENCE

YYYY/MM - YYYY/MM YYYY/MM - YYYY/MM YYYY/MM - YYYY/MM

Field of study:

Education level:

City, Country:

Institution:

Education level:

City, Country:

Institution:

Education level:

City, Country:

Institution:

Start date • End date

12. EDUCATION

Halaman : 28 dari 30 Tgl. Berlaku :

No. Revisil

Terbitan : 0/1

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15.DESCRIPTION OF WORK

Information on your training in radiological protection;

The dose records of the past five years (if available).

i of health fitness to work with ionizing

^No

Please provide:

• A medical certificate or personal declaratio

Radiation Surveillan

I Yes

Please provide the dose records for the past five years.

illance programme in your countiy?

Are you covered under a radial

A medical certificate of good health signed by a registered medical practitioner dated not more than four months prior to the event must be submitted for:

• events with a duration exceeding one month;

r the age of 65 regardless of the e-

If you have a physical disability or medical condition which might limit your ability to perform your assignment, please indicate the limitations below:

:s and able physically and mentally to carry 01 i declare that I am in good health, free from infectious i

duties away from home.

I Yes "

14. HEALTH AND RADIATION

Description of Duties:

Halaman : 29 dari 30 Tgl. Berlaku :

No.Revisi/

Terbitan on

„„_„. : SOP 076.002/

KS 01 04/HHK 3.2

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DATE: (YYYY-MM-DD)

SIGNATURE OF NLO

DATE: (YYYY-MM-DD)

SIGNATURE OF COUNTERPART

No facts are known to the nominating authority regarding the reliability and character of the nominee which w obstruct giving him/her access to nuclear installations or institutions where ionizing radiation is used.

is as a participant ir mtinue to receive during the meetin^

Intents in his/her home country;

with his/her ities;

id correct;

itry(ies) and host institution(s) do not accept liability for the lage to or loss of persona! property, or from illness, injury,

id from or attending the meeting and it, the nominating The nominating authority gives the following assurances:

•All information supplied by the applicant is complete

•It is noted that the sponsoring organization(s), host cc payment of any costs or compensation arising from d;

disability or death of the nominee while he/she is travellinj authority, undertakes the responsibility for such coverage;

•The position of the nominee will be retained for him/her and he/she will c and related emoluments to enable him/her to meet his/her financial comm

•The selected nominee will conduct himself^herself in a manner compatibh event and will refrain from engaging in any political and commercial actii