Formulir Skp Perawat Penyelia

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FORMULIR SASARAN KERJA

PEGAWAI NEGERI SIPIL

N

NOO II. . PPEEJJAABBAAT T PEPENNIILLAAII NNOO IIII. . PPEEGGAAWWAAI I NNEEGGEERRI I SIIPSPIIL L YYAANNG G DDIINNIILLAAII

11 NNaammaa HH. . JJOOSSRRIIZZAAL L HHEELLMMAANN, , SS..SSii, , AApptt 11 NNaammaa NNss. . HHEENNDDRRA A HHAASSRRIIAANNTTOO, , SS..KKeepp 22 NNIIPP 1199668866229 9 11999999! ! 1 1 22 22 NNIIPP 11998866111122  2211""1 1 1 1 11 "" PPaa##$$%%aatt&&''(())..RR**aa##$$ PPeemm++ii##a a & & II  aa "" PPaa##$$%%aatt&&''(())..RR**aa##$$ PPee##aatta a MM**--a a & & IIIII I aa

 JJaa++aattaa## KKeeppaa))aaPP**ss%%eessmmaass  JJaa++aattaa## PPee//aa00aatt

!! ##iit t KKee//aa PP**ss%%eessmmaas s SS**##$$aai i 33**##$$%%aa)) !! ##iit t KKee//aa PP**ss%%eessmmaas s SS**##$$aai i 33**##$$%%aa))

N NOO IIIIII. . KKEEGGIIAATTAAN N TTUUGGAAS S JJAABBAATTAANN AAKK TARGET TARGET K KUUAANNTT//OOUUTTPPUUTT KKUUAALL//MMUUTTUU WWAAKKTTUU BBIIAAYYAA 11 mmee))aa%%**%%aa# # ppee##$$%%aaiiaa# # %%eeppee//aa00aattaa# # --aassaa/ / ppaa--a a ii##--ii44**--** ..22 11..66 88 ppaassiiee## 11 112 2 55 22 mmee))aa%%**%%aa# # ppee##$$%%aaiiaa# # %%eeppee//aa00aattaa# # --aassaa/ / ppaa--a a %%ee))**aa//$$aa .."" ..1188 66 %%ee))**aa//$$aa 11 112 2 55

"" mmee))aa%%**%%aa# # ppee##$$%%aaiiaa# # %%eeppee//aa00aattaa# # --aassaa/ / ppaa--a a %%ee))((mmpp((%% ..11 ..11 11 %%ee))((mmpp((%% 11 112 2 55

 mmee))aa%%**%%aa# # ppee##$$%%aaiiaa# # %%eeppee//aa00aattaa# # --aassaa/ / ppaa--a a mmaassaa//aa%%aatt .."" ..1188 66 --eessaa 11 112 2 55 !! mmee))aa%%**%%aa# # %%((##ss**))ttaassi i ppee##$$%%aaiiaa# # %%eeppee//aa00aattaa# # --aassaa// ..11 88 88 ppaassiiee## 11 112 2 55 66 mmee))aa%%ssaa##aa%%aa# # aa##aa))iissa a --aatta a **##tt**% % mmee//**mm**ss%%aa# # --iiaa$$##((ssa a --aa# # aa##aa))iissa a ppaa--a a ii##--ii44ii--** ..11 ..88 88 ppaassiiee## 11 112 2 55 77 mmee))aa%%ssaa##aa%%aa# # aa##aa))iissa a --aatta a **##tt**% % mmee//**mm**ss%%aa# # --iiaa$$##((ssa a --aa# # aa##aa))iissa a ppaa--a a %%ee))**aa//$$aa ..!! ..66!! 11"" %%ee))**aa//$$aa 11 112 2 55

88 mmee))aa%%ssaa##aa%%aa# # aa##aa))iissa a --aatta a **##tt**% % mmee//**mm**ss%%aa# # --iiaa$$##((ssa a --aa# # aa##aa))iissa a ppaa--a a %%ee))((mmpp((%% ..11!! ..2211 11 %%ee))((mmpp((%% 11 112 2 55

99 ..22 ..2288 11 --eessaa 11 1122 55

11 mmee//ee##aa##aa%%aa# # ttii##--aa%%aa# # %%eeppee//aa00aattaa# # ssee--ee//aa##a a ppaa--a a ii##--ii44**--** ..11 ..88 88 ppaassiiee## 11 112 2 55 1111 mmee//ee##aa##aa%%aa# # ttii##--aa%%aa# # %%eeppee//aa00aattaa# # ssee--ee//aa##a a ppaa--a a %%ee))**aa//$$aa ..22 ..1122 66 %%ee))**aa//$$aa 11 112 2 55 1122 mmee//ee##aa##aa%%aa# # ttii##--aa%%aa# # %%eeppee//aa00aattaa# # ssee--ee//aa##a a ppaa--a a %%ee))((mmpp((%% ..!! ..77 11 %%ee))((mmpp((%% 11 112 2 55

me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a masa/a%at

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1" me/e#a#a%a# ti#-a%a# %epe/a0ata# se-e/a#a pa-a i#-i4*-* .7 !.6 8 pasie# 1 12 5

1 me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i I .1 ." " ti#-a%a# 1 12 5

1! me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i II .2 .1 ! ti#-a%a# 1 12 5

16 me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i III .2   ti#-a%a# 1 12 5

17 melakukan penyuluhan pada individu .1 .8 8 pasie# 1 12 5

18 melakukan penyuluhan pada keluarga ." .18 6 %e)*a/$a 1 12 5

19 _{melakukan penyuluhan pada kelompok} .1 .1 1 %e)(mp(% 1 12 5

2 _{melakukan penyuluhan pada masyarakat} . .2 6 -esa 1 12 5

21 Menyusun rancangan pelatihan untuk kader .1 .1 1 %e$iata# 1 12 5

22 melaksanakan pelatihan kader .6 .6 1 %e$iata# 1 12 5

2" membimbing kader dilapangan .6 .18 " %e$iata# 1 12 5

2 melakukanTugas anastesi operasi kecil .2 .8  ti#-a%a# 1 12 5

2! melaksanakan tugas instrumentator pada operasi kecil .2 .8  ti#-a%a# 1 12 5

26 melakukan tugas limpahan .1 .2 2 ti#-a%a# 1 12 5

27 Melaksanakan evaluasi keperawatan sederhana pada individu .1 .8 8 pasie# 1 12 5

28 _{Melaksanakan evaluasi keperawatan sederhana pada keluarga} ." .18 6 %e)*a/$a 1 12 5

29 _{Melaksanakan evaluasi keperawatan sederhana pada kelompok} .1 .1 1 %e)(mp(% 1 12 5

" _{Melaksanakan evaluasi keperawatan sederhana pada masyarakat} .2 .12 6 -esa 1 12 5

"1 Menerima konsul evaluasi keperawatan secara sederhana pada individu .2 1.6 8 pasie# 1 12 5

"2 Menerima konsul evaluasi keperawatan secara sederhana pada kelompok .7 .98 1 -esa 1 12 5

Sungai Penuh, 01 Maret 2015

Peabat Penilai, Pegawai !egeri Sipil "ang #inilai

H. JOSRIZAL HELMAN, S.Si, Apt Ns. HENDRA HASRIANTO, S.Kep

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PENILAIAN CAPAIAN SASARAN KERJA

PEGAWAI NEGERI SIPIL

*angka +aktu Penilaian % *anuari s%d% )1 #esember 20%%

NO I. Kegit! T"gs J#t! AK TARGET AK REALISASI

-uant. /utput -ual.Mutu +aktu iaya -uant. /utput -ual.Mutu +aktu

$ % & ' ( ) * +  $- $$

1 me)a%*%a# pe#$%aia# %epe/a0ata# -asa/ pa-a i#-i4*-* 1.6 8 pasie# 1 12  5 ".2 1622 pasie# 1 12 

2 me)a%*%a# pe#$%aia# %epe/a0ata# -asa/ pa-a %e)*a/$a .18 6 %e)*a/$a 1 12  5 ." 1 %e)*a/$a 1 12  " me)a%*%a# pe#$%aia# %epe/a0ata# -asa/ pa-a %e)(mp(% .1 1 %e)(mp(% 1 12  5 ." " %e)(mp(% 1 12 

 me)a%*%a# pe#$%aia# %epe/a0ata# -asa/ pa-a masa/a%at .18 6 -esa 1 12  5 .9 " -esa 1 12 

! me)a%*%a# %(#s*)tasi pe#$%aia# %epe/a0ata# -asa/ 8 8 pasie# 1 12  5 16.22 1622 pasie# 1 12 

6 me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a i#-i4i-* .8 8 pasie# 1 12  5 1.622 1622 pasie# 1 12  7 me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a %e)*a/$a .6! 1" %e)*a/$a 1 12  5 .! 1 %e)*a/$a 1 12  8 me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a %e)(mp(% .21 1 %e)(mp(% 1 12  5 .! " %e)(mp(% 1 12  9 me)a%sa#a%a# a#a)isa -ata *#t*% me/*m*s%a# -ia$#(sa -a# a#a)isa pa-a masa/a%at .28 1 -esa 1 12  5 .6 " -esa 1 12  1 me/e#a#a%a# ti#-a%a# %epe/a0ata# se-e/a#a pa-a i#-i4*-* .8 8 pasie# 1 12  5 1.622 1622 pasie# 1 12  11 me/e#a#a%a# ti#-a%a# %epe/a0ata# se-e/a#a pa-a %e)*a/$a .12 6 %e)*a/$a 1 12  5 .2 1 %e)*a/$a 1 12  12 me/e#a#a%a# ti#-a%a# %epe/a0ata# se-e/a#a pa-a %e)(mp(% .7 1 %e)(mp(% 1 12  5 .1! " %e)(mp(% 1 12  1" me/e#a#a%a# ti#-a%a# %epe/a0ata# se-e/a#a pa-a i#-i4*-* !.6 8 pasie# 1 12  5 11."! 1622 pasie# 1 12  1 me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i I ." " ti#-a%a# 1 12  5 .! ! ti#-a%a# 1 12 

1! me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i II .1 ! ti#-a%a# 1 12  5 .8  ti#-a%a# 1 12 

16 me)a%sa#a%a# ti#-a%a# %epe/a0ata# -asa/ %ate$(/i III   ti#-a%a# 1 12  5   ti#-a%a# 1 12 

17 me)a%*%a# pe#*)*a# pa-a i#-i4i-* .8 8 pasie# 1 12  5 1.622 1622 pasie# 1 12 

18 me)a%*%a# pe#*)*a# pa-a %e)*a/$a .18 6 %e)*a/$a 1 12  5 ." 1 %e)*a/$a 1 12 

19 me)a%*%a# pe#*)*a# pa-a %e)(mp(% .1 1 %e)(mp(% 1 12  5 ." " %e)(mp(% 1 12 

2 me)a%*%a# pe#*)*a# pa-a masa/a%at .2 6 -esa 1 12  5 .12 " -esa 1 12 

21 Me#*s*# /a#a#$a# pe)atia# *#t*% %a-e/ .1 1 %e$iata# 1 12  5 .1 1 %e$iata# 1 12 

22 me)a%sa#a%a# pe)atia# %a-e/ .6 1 %e$iata# 1 12  5 .6 1 %e$iata# 1 12 

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2 me)a%*%a#T*$as a#astesi (pe/asi %ei) .8  ti#-a%a# 1 12  5 .86 " ti#-a%a# 1 12 

2! me)a%sa#a%a# t*$as i#st/*me#tat(/ pa-a (pe/asi %ei) .8  ti#-a%a# 1 12  5 .8  ti#-a%a# 1 12 

26 me)a%*%a# t*$as )impaa# .2 2 ti#-a%a# 1 12  5 .2 2 ti#-a%a# 1 12 

27 Me)a%sa#a%a# e4a)*asi %epe/a0ata# se-e/a#a pa-a i#-i4i-* .8 8 pasie# 1 12  5 1.622 1622 pasie# 1 12  28 Me)a%sa#a%a# e4a)*asi %epe/a0ata# se-e/a#a pa-a %e)*a/$a .18 6 %e)*a/$a 1 12  5 ." 1 %e)*a/$a 1 12  29 Me)a%sa#a%a# e4a)*asi %epe/a0ata# se-e/a#a pa-a %e)(mp(% .1 1 %e)(mp(% 1 12  5 ." " %e)(mp(% 1 12  " Me)a%sa#a%a# e4a)*asi %epe/a0ata# se-e/a#a pa-a masa/a%at .12 6 -esa 1 12  5 .6 " -esa 1 12  "1 Me#e/ima %(#s*) e4a)*asi %epe/a0ata# sea/a se-e/a#a pa-a i#-i4i-* 1.6 8 pasie# 1 12  5 ".2 1622 pasie# 1 12  "2 Me#e/ima %(#s*) e4a)*asi %epe/a0ata# sea/a se-e/a#a pa-a %e)(mp(% .98 1 -esa 1 12  5 .21 " -esa 1 12 

"" :RE;<  :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;<

" :RE;<  :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;< :RE;<

II. TUGAS TAMBAHAN DAN KREATIITAS/UNSUR PENUNJANG  1 0t"gs t1#2!3 0t"gs t1#2!3 2 045eti6its3 045eti6its3

Ni7i 8pi! SKP

 H.J !$

(5)

PENGHITUNGAN

iaya persen waktu persen biaya kuantitas kualitas waktu biaya

$% $& $'

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UNSURYANGDINILAI Jumlah

6. TANGGAPAN PEJABAT PENILAI

#REF! x 60% #REF! ATAS KEBERATAN

1. Orientasi Pelayanan 70 (Cukup)

2. Integritas 9 (angat "aik)

. $%&it&en 91 (angat "aik)

'. isiplin 0 (e*ang)

. $er+asa&a ,0 ("aik)

. $epe&i&pinan 90 ("aik)

7.-u&la ', Tanal """"""".

,. /ilai rata  rata ,1.00 ("aik)

. KEPUTUSAN ATASAN PEJABAT

$. Nla P&'la(u K&')a *+.00 x ,0% 2.'0 PENILAI ATAS KEBERATAN

#REF!

NILAI PRESTASI KERJA #REF!

-. KEBERATAN DARI PEGAAI NEGERI SIPIL YANG DINILA I /APABILA ADA

Tanal """" """. Tanal """"""".

,.

a. Sa1a'an K&')a P&a2a /SKP

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*. REK45ENDASI

PENILAIAN PRESTASI KERJA PEGAAI NEGERI SIPIL

$EE/ERI3/ PE$ER-33/ 44 -3/5$3 63$4 PE/I3I3/

IRE$OR3 -E/ER3 "I/3 3R53 "43/ 8 -anuari s* 1 ese&:er 20.... +.

YANG DINILAI

!s% C@!#8= C=S8$=!T/, S%-ep

$. DIBUAT TANGGAL """".. 1&('1120 201)01 1 001

PEJABAT PENILAI _{Penata Muda . $$$ a}

Perawat

. J4SRI7AL EL5AN S.S A89 Puskesmas Sungai ungkal

19,029 19990 1 002 :.

PEJABAT PENILAI

+0. DITERI5A TANGGAL """" C% */S8$D=> C@>M=!, S%Si, =pt

PEGAAI NEGERI SIPIL YANG DINILAI _{1&'(0'2& 1&&&05 1 002}

Pembina . $< a

N1. ENDRA ASRIANT4 S.K&8 -epala Puskesmas

19,1120 20101 1 001 _{Puskesmas Sungai ungkal}

++.DITERI5A TANGGAL . ... ...

;.

ATASAN PEJABAT PENILAI

0 0

a. / a & a :. / I P

;. Pangkat< 5%l%ngan ruang<  *. -a:atanPeker+aan

e. 4nit Organisasi

a. / a & a :. / I P

e. 4nit Organisasi

a. / a & a :. / I P

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