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APLIKASI KREDENSIALING KEPERAWATAN

 A. IDENTITAS

Nama Pemohon : ................................................................................................... NIP/ NIP/NI NIK K : .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .. ........ Tangga nggall Lahi Lahirr : .... ....... ..... .... ../.. /.... .... ..... ..../ ./.. ..... ..... .... .... .. (tanggal/bulan/tahun) tanggal/bulan/tahun) Mulai kerja kerja di RSDK : .........../........../........... (tanggal/bulan/tahun (tanggal/bulan/tahun)) Ruang :........................................E!en"io No :..................................... Tele#on : ................................. $P : ............................................ Emai Emaill : .... ...... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ........ ...... ........ ...... ........ ...... ...... ....... STATUS REGISTRASI B. STATUS

(saat ini)

Nomor Regi"!ra"i : .............................................................................. Nomor Ija%ah : .............................................................................. Nama In"!i!u"i Pendidikan : .............................................................................. Tanggal Tanggal Lulu" : .............................................................................. Kuali&ik &ika"i Pe Pendidikan : Di Di#loma/Ne /Ner"/ S# S#e"iali"....... ......... ............ ........ Penjenjangan Karir : PK ' / I / II / III / I / .............................................. Nomor "er!i&ika! kom#e!en"i : .............................................................................. Ma"a erlaku "am#ai : ........./........../........... (tanggal/bulan/tahun

STATUS KREDENSIALING KREDENSIALI NG YANG DIUSULKAN(Berikan DIUSULKAN (Berikan ceklist pada salah C. STATUS satu kotak)

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Useful  Not useful ........................  *+al  Kenaikan !ingka!  Pemulihan Ke+enangan

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.................................................................................................................. ......*#akah ke+enangan klini" anda #ernah : Dikurangi 0a Tidak Diekukan 0a Tidak Di2au! 0a Tidak ika0a1 !uli"kan ka#an hal !er"eu! !erjadi. .................................................................................................................. ...... 3. *#akah anda #ernah menda#a! !eguran / #eminaan di"i#lin dari a!a"an 0a Tidak .................................................................................................................. ... • • •

4. Tuli"kan ke+enangan klini" -ang diu"ulkan e"er!a uk!i5uk!i #enduku ("e"uai uku #u!ih)

No

KewenanganKlinis Yang Diinginkan

BktiPen!kng

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5.

Tuli"kan #rogram #engemangan #ro&e""ional erkelanju!an (6PD) a #era+a! -ang anda iku!i dalam 3 !ahun !erakhir 

Tahun Kegia!a n

7uk!i (Nomor  Sertifikat/  Surat  Tugas/SK)

In"!i!u"i Pen-elenggara Kegia!an

eni" Kegia!an

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Tanda Tangan

: ................................................................

Nama ela" huruf cetak)

:

Tanggal

: ........./........../.......... (Tanggal/Bulan/Tahun)

................................................................. (Tulis denga

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A. I!entitas NamaPera+a! .........

: .........................................................................

Kuali&ika"i : PK '/ ....................................................... Tanggal

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3

%. Da&ta" Kewenangan Klinik Yang Dislkan

Ke+enangan klinik dierikan ke#ada "e!ia# #era+a! "e"uai jenjang karir1 #er dilakukan kreden"ial !erhada# ke+enangan klini" un!uk mem#er #enuga"an klinik. Penuga"an klinik -ang dierikan dalam rangka memerika a"uhan ke#era+a!an di RS kariadi un!uk memenuhi keu!uhan da"ar #a"ie dan keluarga. Pro"e" kreden"ial dimulai dengan #era+a! "e2ara menggamarkan kemam#uan "aa! ini dengan kri!eria : , 9 Kom#e!en 8 9 Dengan Su#eri"i 3 9 7elum Kom#e!en Selanju!n-a Su Komi!e Kreden"ial er"ama Mi!ra 7e"!ari melaku kreden"ial dengan ha"il : , 9 7er+enang Penuh 8 9 Dengan Su#eri"i 3 9 7ukan Ke+enangan Selanju!n-a rekomenda"i diua! !erhada# "e!ia# ke+enangan klini" (6P dengan kri!eria : S 9 Se!uju TS 9Tidak Se!uju Ke+enangan klini" #era+a! klinik : ' / I / II / III / I .............................................. You're Reading a Preview ;n!uk keahlian ke#era+a!an: Da"ar dan umum Unlock full access with a free trial. 7edah Medikal Emergen"i/ Kri!ikal  *nak Ma!erni!a" Download With Free Trial ................................

Pro"e" Kreden"ialing N o

Ke+enangan Klini"0ang Dimin!a

Kemam#ua n Saa! ini

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Tin!akan an!i"i

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elakkanTin!akanKola*o"asi

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Silahkan menamahkan #ada halaman lain jika kolom ini !idak men2uku#i +

elakkan Pen!i!ikan Kese,atan

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Catatan oleh Ketua Sub Komite Kredensial : Useful

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Besta"i  NamaTandaTangan

,. <<<<< ,. <<<< 8.

<<<<<.8. <<

+.  <<<<<.3. <<<<

Pe"awatKlinik  Nama :.................<<<

Catatan :

TandaTangan: <<<<< Tanggal :......................

E. Pe"set/an Keta S* Ko$ite K"e!ensial Nama

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TandaTangan Tanggal

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