g KEMENTERIAN KESEHATAN REPUBLIK INDONESIA rie SEKRETARIAT JENDERAL » Ji. HR. Rasuna Said Blok X-5 Kavling 4-9, Jakarta 12950 Telp. (021) 5201590 (Hunting) GERMAS SURAT KETERANGAN Nomor ; HJ.02.02/1/5% /2022 Yang bertanda tangan dibawah ini : Nama dr. Budi Sylvana, MARS, MH Jabatan Kepala Pusat Kesehatan Haji Instansi_ —_: Kementerian Kesehatan MEMPERHATIKAN, Petugas _: Tenaga kesehatan Haji Kloter Indonesia Tujuan : Misi Haji Indonesia Untuk kebutuhan pelayanan kesehatan Jemaah Haji Indonesia diharuskan membawa Obat-obatan sebagai berikut : No Nama dan Jenis Obat Satuan Jumiah’ Daftar Terlampir Berdasarkan alasan medis, obat-obatan diatas dibawa oleh petugas kesehatan untuk pelayanan kesehatan Jemaah Haji Indonesia. Surat keterangan ini ditunjukkan kepada Otoritas Arab Saudi pada saat kedatangan untuk izin keluar barang Jakarta, 20 Mei 2022 a Pusat Kesehatan haji #97504012002121002MINISTRY OF HEALTH REPUBLIC OF INDONESIA @ af? HR, Rasuna Said Street Block X-5 Kavling 4-9 Jakarta 12950 Phone (+6221) 5201590 (Hunting) TO WHOM IT MAY CONCERN No. : HJ.02.02/1/'st 2022 The Undersigned below : Name : dr. Budi Sylvana, MARS, MH Position : Head of Hajj Health Centre Institution: Ministry of Health Republic Indonesia NOTIFIES THAT Officer _: Indonesian Hajj Health Team Purpose : Indonesian Haj Mission For the health service needs of Indonesian Hajj Pilgrims required to carry medicines as follows: No | Name/kind of medicine Unit ‘Amount List Attached Based on medical reasons, the medicines above were brought by health officers to the health services of the Indonesian Hajj Pilgrims. This notification is shown to the Saudi Arabian Authority when necessary upon arrival for clearence Yylvana, MARS, MH ” 197504012002121002MINISTRY OF HEALTH REPUBLIC OF INDONESIA e HR. Rasuna Said Street Block X-5 Kavling 4-9 Jakarta 12950 Phone (-+6221) 5201590 (Hunting) pail lbs HJ.02,02/1/ 05/2022 a8. pobal ged gal) U) MH «MARS < Wiles gags: eal Gall anal oe at roma) Hana 3 Ans Mads Jatt Tiga Gall Atty Lo gene igen glial: gal Ayal gsil Gall ey asl AMON Ay gH) laa! Capen ATVI Clg le yal « Ayaaall GLaddl) Glalioy Esa Fag Flgall g 935 pal el AB yall La asi Gyre Culabell Jub (ya odLe| 5 9S Ay galt) ada) Yalu) apie BL geargl sic Aya gesall yy lh ASL) aden og!) Bulge) od pps py Lua gti} laa Laval) gee Gaga S022 he 20: seDaftar Obat dan Perbekalan Kesehatan Tas Kioter: 1. | Alkohol swabs Piece 50 2. | Disposible syringe 3 ce Piece 5 3 | Weatheter 22 6 Piece 2 4 | intus set Piece 1 5. | Kasa Sterile Uk kecil 16 om x 16 em Box @ 16 pads 1 6 _| Plastik obat ukuren sedang (7 x 10 om) Piece 100 7_| Prastik obat ukuran besar (12 x 20 cm) Piece 100 8_| Disposible syringe 10 cc Piece D 8 | Spacer Portable 175 ce Piece 1 10 | Povidon lodide 10% 30 mi Botol al 11_| Amiodipin 5 mg Tabiet 20 412 | Amoxycilin 500 mg Tablet 100 13 | Aasia tombines: Aluminium hyeroxde, Magnesium hye, eer a 44 | Asam Mefenamat 500 mg Tablet 100 16 | Attapuigit alti 600 ma Tablet 30 416 | Betahistin Mesiiat 8 mg Tablet 10 17 | Bromhexin HCI 8 mg Tabiet 00 18 | Captopril 25 mg Tablet 100 19 | Clopidogrel 75 mg Tablet 20 20 | Cotrimoksazol (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) Tablet 20 21 | Dimenhirinat 50 mg Tablet 50 22 | Domperidon 10 mg Tablet 20 23 | Furosemide 40 mg | Tablet 10 24 | Garam Oralit | Sachet 25 25 | Metformin HCL 600 mg [ Tabiet 100 26 | Natrium Diklofenak 50 mg [Tablet 10 27_| Isosorbid Dinitrat (ISDN) 5 mg | Tabiet 10 28 | Loretadine 10mg Tablet 100 29 | Renitidin 150 mo Tablet 30 30 | Diazepam 6 mg Tablet 20 31_| Paracetamol 500 mg Tablet 20 32 | Salbutamol 100 meg/puff Inhaler 1 38 | Clonidin 0,15 mg Tablet 10 34 | Clonidin inj 0,1 mgiml “Ampul 2 35_| Dexamethason inj § mg/ml ‘Ampul 1 36 | Dextrose 40% Botol 26 mi 2 237_| Diphenhydramine inj 10 mgimt “Ampul i 38 | Epinefrin inj 0,4% Ampul 1 30 | Natrium Kiorida 0,9% infus Botol 100 mi 2 [ 40 | Furosemid inj 10 mg/ml ‘Ampul 2 gentron inj 4 mg/2 mi “Ampul 2List of Drugs Kloter's Bag: 1__| Alcohol swabs Piece 50 2_| Disposible syringe 3 cc Piece 5 3 | IVeatheter 226 Plece 2 4 | Infus set Piece 1 5 | Kasa Sterile Uk.kecil 16 cm x 16 cm Box @ 16 pads t 6 _| Plastik obat ukuran sedang (7 x 10 em) Piece 100 7 _| Plastik obat ukuran besar (12 x 20 cm) Piece 100 8 | Disposible syringe 10 cc Piece 2 9 _| Spacer Portable 175 cc Piece = 10 | Povidon lodide 10% 30 mi Botol 1 11_| Amlodipine 5 mg Tablet 20 12_| Amoxycillin 500 mg Tablet 100 19 | Ai embnas Aurion ryeronde, Magnesium Rao, a) a 14 | Mefenamic Acid Tablet 100 15 | Betahistin Mesilat 8 mg Tablet 10 16 | Attapulaite Aktivated 600 mg Tablet 30 17 | Bromhexin HCI 8 mg Tablet 100 18 | Captopril 25 me Tablet 100 19 | Clopidogrel 7 mg Tablet 20 20 | Cotrimoxazole (Trimethoprim 80 mg, Sulfamethoxazole 400 mg) Tablet 20 21 | Dimenhydrinate 50 mg Tablet 50 22 | Domperidone 10 mg Tablet 20 23 | Furosemide 40 mg Tablet 10 24 | Orel rehydration therapy. Sachet 25 25 | Metformin HCL 500 mg Tablet 100 26 | Natrium Diclofenac 50 mg Tablet 10 27 _| Isosorbid Dinitrat (ISDN) 5 mg Tablet 10 28 | Loratadine 10 mg i Tablet 100 29 | Ranitidine 160 mg Tablet 30 30 | Diazepam § ma Tablet 20 31_| Paracetamol 500 mg Tablet 20 32 | Salbutarol 100 meg/puff Inhaler 1 33 | Clonidin 0,15 mg Tablet 10 34 | Clonidin inj 0,15 mg/ml Ampul_ 2 35 | Dexamethason inj § mg/ml “Ampul 1 36 | Dextrose 40% Botol 25 ml b 37 | Diphenhyaramine in 10 ma/ml “Ampul 1 38 | Epinefrin inj 0,1% Ampul Md rum Korda 0,9% infus oto! 100 mi 2 mide inj 10 righ “Ampul 2 tron inj 4 mg/2 mi Ampul 2Abel) che jliswally Lgaiit) Lait 50 aabs UseSll Slawe 1 5 abs C03 Igio jalatll (Say is 2 2 aabs 22 day yillG 3 1 dabs cit puill acgan0 4 1 glo 1616 (Lill dauto 6 16csbeio 100 dab 10x7a gol i> ayo 6 100 asbs 20x12% 9901 Bb> ayui> F 2 aabs pall aia> 8 1 ‘anki Wgarall Jol 2 1 db _ 031% 10 3eull gosidoy 10 20 toy) lo 5 oupdglal 1 100 by) 500 gulumuSea! 42 100 ey) snSgy 3a + pgulogll ayuiSeyaehiguly pail 3 lu sluaulpaieg> aphasia 100. ee ypligigall yao 4 10 ae) B Nae juan 15 30 ay) 222 600 buts) cuales 16 100 al Be Bh Sy ygll yaar candsoaye 7 +100. ‘tea! o25 enol 18 20 aol H275 Uso sais 18 20 By | dajluSgholiln . ano 80 eisishial) JsiluSsassisS | 99 22 400 50 el 3 50 Sly ging zi 20 aa Ble 10 yoy yttes> 22 10 ao) gled0 5 2B 25 | cub yu Sal alle 24 100 tea) ‘ate, paigall HCL 500 lo 25 10 ay) eS Joy ella 26 10 Fer 222 50 pas si lb gIS)9 2 100 dy) Blo10 yydtihel zal 30 ag lo 150 asi 29 20 as) BleSply ball 30 20 ay) £1500 Jooligul Ll u 1 ‘Salbwall 100 G58 / plea Spo Joolizallu 32 10 1 120,15 ypsuigISII 33 2 Em) Uo/ 100,152 jal Gy agiglSIl 34 1 Ugo! 022 50 p9s;ili dligbglS)9 35 2 Jo25 ale) ZA0 jgytuSal 36 af Wayol %A0 jqyiaS all 7 1 guol 0,12 5> ou sisal 3 2 Jet00a>l>5 %O,1 agidguall yglS ho 38. 2 Dayal of ilo10 spores a 2 Usual ~offleda) gastsuslaigh “1