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APLIKASI KREDENSIALING KEPERAWATAN

  A. IDENTITAS
Nama Pemohon
: ...................................................................................................
NIP/NIK : ..................................................................................
........
Tanggal Lahir : .........../........../..............(tanggal/bulan/tahun)
Mulai kerja di RSDK : .........../........../...........(tanggal/bulan/tahun)
Ruang ...............................................................................................................E!en
No :.....................................
Tele#on : .................................
$P : ............................................
Email : ..................................................................................
.......

B. STATUS REGISTRASI (saat ini)

Nomor Regi"!ra"i
: ..............................................................................
Nomor Ija%ah
: ..............................................................................
Nama In"!i!u"i Pendidikan
: ..............................................................................
Tanggal Lulu"
: ..............................................................................
Kuali&ika"i Pendidikan : Di#loma/Ner"/ 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/ta

C. STATUS KREDENSIALING YANG DIUSULKAN(Berikan ceklist pada sal

satu kotak) 
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 *+al  Kenaikan !ingka!  Pemulihan
KUes+efuelnangaNnotus..e.f.u..l...............
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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"
0a Tidak
..............................................................................................................
...

4. Tuli"kan ke+enangan klini" -ang diu"ulkan e"er!a uk!i5uk!i #endu

("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)

#era+a!- ang anda iku!i dalam 3 ! ahun !erakhir 

7uk!i
Tahun (Nomor S In"!i!u"i
Kegia!a ertifikat/ S Pen-elenggara eni" Kegia!an
n urat Tuga Kegia!an
s/SK)

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 Sheet Music Tanda Tangan : ................................................................

Nama ela" ...............................................................................................(Tulis den

huruf cetak)

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

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PR#SES KREDENSIALING WATAN

A. I!entitas

NamaPera+a! : ........................................................................
.........

Kuali&ika"i : PK '/ SI ig n u/p t o vIoI te on/ th is tIiItIle
/ I
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Tanggal : ........................................................................

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

Ke+enangan klinik dierikan ke#ada "e!ia# #era+a! "e"uai jenjang karir1 #
dilakukan kreden"ial !erhada# ke+enangan klini" un!uk mem#er #enuga"an
klinik. Penuga"an klinik ang dierikan dalam rangka memer
a"uhan ke#era+a!an di RS kariadi un!uk memenuhi keu!uhan da"ar #a
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 melak
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"
dengan kri!eria :
S 9 Se!uju TS 9Tidak Se!uju
Ke+enangan klini" #era+a! klinik : ' / I / II / III / I
....................... .......................
;n!uk keahlian ke#era+a!an: You're Reading a Preview
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Medikal Emerg en"i/ Kri!ikal
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..................... ...........

Pro"e" Kreden"ialing

N Kemam#ua Reie+ Rekomend

Ke+enangan Klini"0ang Dimin!a
o n Saa! ini / i
alida" 
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Silahkan menamahkan #ada

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

halaman lain jika kolom ini !idak
men2uku#i 
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Besta"i 

NamaTandaTangan
,. <<<<< ,. <<
8. <<<<<.8. <<
+.  <<<<<.3. <<

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

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

E. Pe"set/an

Keta S* Ko$ite K"e!ensial

You're Reading a
Nama ..................
Preview
: ...................................................
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trial.

TandaTangan : ...................................................
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Tanggal . Trial ..................

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