附件 1：

Appendix1：

回国实习申请表

Application Form for Internship in Other Hospital

姓名 性别 Sex Female

Name Rizka Nurazizah 学号 Roll

201741520203
No.

国籍 护照号
Indonesia C8091796
Nationality Passport No.

签证号 签证有效期
Visa No. Valid data
of Visa

国内手机号 邮箱地址
+62
Mobile in 82162210391 E-mail address Rizkainura16@gmail.com
home country

家长信息 姓名 Name 关系 电话 Tel. 邮箱地址 E-mail

Parents’
Relationship address
information
Motasi
Father +6281350553150
Sulistianto

Rusdiana Mother +6281350553150

家庭通讯方式 家庭电话 Tel.

Family Tel in
移动电话
home country +62 81350553150
Mobile

家庭住址 JL.Kemuning Rt.10 No.59, Loa Bakung, Sungai Kunjang,

Samarinda, Kalimantan Timur
Address

实习时间 From July/4/2022 to June/18/2023.

Clinical
practice time

单位信息 单位名称 Drs. H. Amri Tambunan Hospital

Hospital’s
Name
information **大学
Muhammadiyah University of North Sumatera
**University

地质 Address Mh. Thamrin Road No.126, Lubuk Pakam Pekan, Kec. Lubuk
Pakam, Deli Serdang Regency, North Sumatra 20518

网址 Web
rsudhat.deliserdangkab.go.id
address

医院联系电话 (061)795-2068
Tel/Landline
of Hospital

医院联系人姓
名、职务
Contact

person/position

承诺：本人承诺以上提供信息真实有效，如有虚假，将承担一切后果。本人承诺已详细阅读

《湖北理工学院临床医学留学生实习和毕业工作安排》，保证实习期间，遵守医院各项规章
制度，服从科室管理，尊重老师，虚心学习，严格执行各项医疗操作程序，在带教老师指导
下开展各项学习任务，如擅自处理造成不良后果，服从医院处罚。在医院实习期间，本人承
担自身安全责任。

Promise: I hereby affirm that all the information in this table is true and correct. I promise I
have read ‘the Hubei Polytechnic University international students graduate clinical practice
and work schedule’. During the clinical practice, I will abide by the regulations of the hospital,
obey the management department, respect teachers, learn from them, strictly implement the
various medical procedures, learn tasks under the teachers’ guidance in hospital. If my
unauthorized action caused serious consequences, I would obey the hospital punishment.

During my clinical practice in the hospital, I assumed responsibility for my own safety.

签名（Signature）：

日期（Date）：

注：由学生本人填写。
Attention：Fill in by the student himself/herself.
附件 2：
Appendix 2：

国际学生赴校外单位实习信息表
Information Form of the Clinical Practice Hospital for
International Students

实 单位信息 单位名称 Name Drs. H. Amri Tambunan Hospital

习 Hospital’s
单 information 大学 University Muhammadiyah University of
位 North Sumatera
信
地址 Address Mh. Thamrin Road No.126, Lubuk
息 Pakam Pekan, Kec. Lubuk Pakam,
The Deli Serdang Regency, North
Information Sumatra 20518
of 网址 Web address rsudhat.deliserdangkab.go.id
the
Internship 医院联系电话 联系电话
Tel/Landline of (061)795-2068 (061)795-2068
Hospital Tel. of Hospital
Hospital

可开展的实习项目 □ Internal medicine Department

The Departments of
□ Surgery Department
Internship
□ Gynecology and Obstetrics Department

□ Pediatric Department
Others:

□ Dermatovenerology Deparment

□ Ophthalmology Department

单位简介（附件） Drs. H. Amri Tambunan hospital is a General Hospital

Brief Introduction of owned by the Deli Serdang Regency Government, is a
Service Referral Center with Class B Education status
the Hospital
based on the Decree of the Minister of Health of the
Republic of Indonesia. In 2020 Drs. H. Amri Tambunan
（attach introduction）
Deli Serdang Hospital has received a Home Accreditation
certificate Hospital Version SNARS Ed.1 Number: KARS-
SERT/1475/III/2020 with a 5-star Plenary level graduation
from the Hospital Accreditation Commission (KARS).

接 Name : Rizka Nurazizah

收
Roll No. : 201741520203
函
Date of birth : April 16th 1999
Opinion of
Acceptance Home phone : +6282162210391

Passport No. : C8091796

接 单位负责人签名（盖章）：
收 Register of Academy of the Hospital(Stamp and Emboss)
函
Opinion of
Acceptance

日期 Date：

注：由实习医院填写。
Attention：Fill in by the Clinical practice hospital.
附件 3：

Appendix 3：

国际学生校外实习家长确认函

Parents’ Confirmation Letter on Students’ Clinical Practice

Name : Rizka Nurazizah

Roll No :201741520203

Passport No : C8091796

致湖北理工学院国际学院：
家长确认：我是学生家长 ，对于回国实习的事项我已知晓并同意，同时我
也将督促其按照《实习管理规定》及相关要求，切实在规定时间内完成实习任
务，并填写《实习手册》，特此说明。

To the InternationalSchool, Hubei Polytechnic University:

Parents’ Confirmation: I am Rizka Nurazizah ’s
Farther/Mother Motasi Sulistianto. I already know and have agreed that
he/she will come back to our own country to do clinical practice, don’t need to
be arranged by Hubei Polytechnic University. Meanwhile I will also urge
him/her to do internship completely and fill in the clinical practice manual
according to ‘clinical practice provisions’ and the related requirements.

签名 Signature:

日期 Date:
注：由学生家长填写。
Attention：Filled in by the students’ parents.
附件 4：
Appendix4
湖北理工学院国际学生回国或第三方国家实习审批表
Application Form for Internshipin your home country or a third
country of Hubei Polytechnic University

一、回国或第三方国家实习信息：

Information of clinical practice in your home country or a third country

Drs H AMRI 带教老师 带教老师

实习单位名称 TAMBUNAN 邮箱
Name of hospital HOSPITAL Teacher’s
Name E-mail

二、学生基本信息:Student’s information( 请按教务系统中标准信息填写)

六级 专 业 Clinical Medicine 2017 Class 2

年 级 Grad 班 名 Class
Major

学 号 2017415202 姓 名 Rizka Nurazizah Female

03 性 别 Sex
Roll No. Name

三、详细联系方式：Contact

家庭地址 JL.Kemuning Rt.10 No.59, Loa Bakung, Sungai Kunjang, Samarinda, Kalimantan
Timur
Address

邮政编码 75126 收件人 JL.Kemuning Rt.10 No.59, Loa

Bakung, Sungai Kunjang, Samarinda,
postcode addressee Kalimantan Timur

联系电话 Tel. +62 82162210391 邮 箱 E-mail Rizkainura16@gmail.com

四、家庭情况：

父 Motasi 工作单位 Entrepreneur 联系电话 +618135055315

Sulistiant 0
Father Employment Tel.
o

母 Rusdiana 工作单位 Midwife 联系电话 +628135055315

0
Mother Employment Tel.

学院意见： 学工部意见：

International school Department of student management

( 盖章处 Stamp ) ( 盖章处 Stamp )

日期 Date: 日期 Date:
财务处意见： 宿管中心意见：
Department of Finance Department of Dormitory Management

( 盖章处 Stamp ) ( 盖章处 Stamp)

日期 Date: 日期 Date:

教务处意见：

Academic Affairs Office

( 盖章处 Stamp ) 日期 Date:

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