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DEPARTMENT OF EDUCATION UDAYANA UNIVERSITY FACULTY OF MEDICINE ELECTIVE STUDY PROGRAM Head of Program Secretary Students Name Supervisor

: Dr. dr. I.W.P. Sutirta Yasa, M.Si : dr. Putu Ayu Asri Damayanti, M.Kes : :

Special Study Program NO DAY/DATE ACTIVITY SUPERVISOR SIGNATURE

Denpasar, Januari 2012 Verified by Head of Program Secretary

Dr. dr. I.W.P. Sutirta Yasa, M.Si NIP : 19570513 19860

dr. Putu Asri Damayanti, M.Kes NIP : 19780706 20031

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