FORMULIR SERAH TERIMA BARANG

Hari :
Tanggal :

No Nama Barang Merk Type Satuan Jumlah

1 2 3 4 5
1 Bed Obgyn KB Buah 1
2 Lampu sorot Buah 1

Bak instrumen tertutup yang dapat

menyimpan seluruh alat pemasangan Ce Marking
dan pencabutan IUD (disesuaikan german Stainless
3 dengan besar alat) Germany Steel Buah 2

Ce Marking
german Stainless
4 Speculum Vaginal Graves Germany Steel Buah 4

Forcep Sponge Foster Straight (Klem Ce Marking

Pemegang Kasa) panjang 250-270 german Stainless
5 mm / 9-11" Forcep Germany Steel Buah 4

Ce Marking
Tenacullum Schroeder panjang 25 – 27 german Stainless
6 cm / 10" Germany Steel Buah 4

Ce Marking
Uterine Sims panjang 320-330 mm / german Stainless
7 12.5–13" Germany Steel Buah 3

Ce Marking
german Stainless
8 Scissor (Gunting ) Germany Steel Buah 1

Ce Marking
IUD Removal Hook panjang 320 mm / german Stainless
9 12.5" Germany Steel Buah 1

Ce Marking
Mangkok antiseptik : diameter atas 6-8 german Stainless
10 cm atau iodine cup ukuran 0.06-0.07 L Germany Steel Buah 2
Stainless
Steel

Ce Marking
german Stainless
11 Bak intrumen kecil Germany Steel Buah 1

Ce Marking
german Stainless
12 Mosquito atau klem lengkung Germany Steel Buah 1

Ce Marking
german Stainless
13 Klem u Germany Steel Buah 1

Ce Marking
german Stainless
14 Pinset anatomis Germany Steel Buah 1

Ce Marking
german
Ce Marking Stainless
15 skalpel atau pemegang bisturi Germany
german Steel
Stainless Buah 1
16 Trokart dan pendorongnya Germany Steel Buah 1
Yang menyerahkan Yang menerima
NIP : NIP :