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UPT PUSKESMAS................................

LAPORAN FASILTAS KESEHATAN TRADISIONAL

Bulan..............................
JENIS
NAMA FASKES ALAMAT NO. IZIN FASKESTRA NAMA PENYEHAT JAM
NO PELAYANAN
TRADISIONAL FAKSETRADISIONAL DAN MASA BERLAKU TRADISIONAL PELAYANAN
TRADISIONAL

....................................,.................................................20....
Kepala UPT. Puskesmas........................................

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NIP................................................................
UPT PUSKESMAS........................

LAPORAN PELAYANAN KESEHATAN TRADISIONAL


Bulan :
JENIS KELAMIN
FASKES ALAMAT FASKES NAMA PENYEHAT KLIEN JENIS CARA
NO NAMA KLIEN METODE
TRADISIONAL TRADISIONAL TRADISIONAL LAKI- PEREMPU PENYAKIT PELAYANAN
LAKI AN

..................., ...............................20....
Kepala UPT Puskesmas...............................

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NIP.................................................................
UPT PUSKESMAS..........................................................

LAPORAN TENAGA PENYEHAT TRADISIONAL

Bulan.............................

NAMA PENYEHAT ALAMAT PRAKTEK DAN NO NO. STPT DAN NO. STRTKT MASA NO. SIPTKT MASA JENIS PENYAKIT
No
TRADISIONAL TELP MASA BERLAKU BERLAKU BERLAKU YANG DIOBATI

Keterangan : .....................,...........................20
1 STPT = Surat Tanda Penyehat Tradisional Kepala U{PT Puskesmas.....................
2 STRTKT = Surat Tanda Registrasi Tenaga Kesehatan Tradisional
3 SIPTKT = Surat Izin Praktik Tenaga Kesehatan Tradisional

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NIP................................................
UPT PUSKESMAS............................................

LAPORAN OBAT TRADISIONAL DAN ALAT YANG DIGUNAKAN PENYEHAT TRADISIONAL


Bulan..................................
NAMA PENYEHAT OBAT / RAMUAN YANG DIGUNAKAN ALAT YANG
NO ALAMAT PRAKTEK KET
TRADISIONAL NAMA DAERAH NAMA INDONESIA DIGUNAKAN

Keterangtan : ................................................20
Obat / Ramuan disebutkan tanaman atau bahan Kepala UPT Puskesmas.....................
yang digunakan.

.................................................
NIP...........................................
UPT PUSKESMAS........................

LAPORAN PEMILIK LAHAN TANAMAN OBAT KELUARGA (TOGA)


Bulan :

NAMA PEMILIK JENIS TANAMAN OBAT


NO ALAMAT LUAS LAHAN TOGA KETERANGAN
LAHAN TOGA NAMA DAERAH NAMA INDONESIA

....................................,.................................................20....
Kepala UPT. Puskesmas........................................

......................................................................
NIP................................................................
UPT PUSKESMAS........................

LAPORAN TENAGA TRADISIONAL DI PUSKESMAS


Bulan :

No Nama NIP/NRTK2D Pendidikan Terakhir No. Ijazah / No. Srtifikat Keterangan

....................................,.................................................20....
Kepala UPT. Puskesmas........................................

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NIP................................................................