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TECHNICAL INSTRUCTIONS

INDEPENDENT PATHWAY NEW STUDENT ADMISSION SELECTION (SIMAMI)


HEALTH POLYTECHNIC MINISTRY OF HEALTH TANJUNGKARANG
ACADEMIC YEAR 2023/2024

MINISTRY OF HEALTH OF THE REPUBLIC OF INDONESIA


DIRECTORATE GENERAL OF HEALTH WORKERS
POLTEKKES KEMENKES TANJUNGKARANG
YEAR 2023
FOREWORD

Praise our gratitude to the presence of God Almighty for His Mercy and Grace, so
that the Technical Guidelines for Selection of New Student Admissions for the
Health Polytechnic of the Ministry of Health Tanjungkarang Independent Computer
Base Test (CBT) Academic Year (FY) 202 3/2024 can be issued.
The admission of new students of the Health Polytechnic of the Ministry of
Health Tanjungkarang is held to produce qualified Health Workers in accordance
with Professional Standards and Service Standards. The implementation of health
worker education is carried out by taking into account the balance between the
needs of health efforts and the implementation of health services, the balance
between the ability to produce health workers with available resources, the
development of science and technology and the dynamics of job opportunities, both
domestically and abroad.
In
order to expand access for high school graduates throughout Lampung Province in
particular and all Provinces in Indonesia in general who are interested in attending
education in various study programs at the Tanjungkarang Ministry of Health
Poltekkes and in an effort to produce qualified health workers, the Tanjungkarang
Ministry of Health Poltekkes implements Networking new prospective students
through the Sipenmaru mechanism with 3 (three) paths, namely the PMDP (Interest
and Achievement Search), the Simama line (together with all Poltekkes Kemenkes
RI) and the Simami (Independent) route.
Just like other Kemenkes Poltekkes, Poltekkes Kemenkes Tanjungkarang
organizes new student admissions by utilizing Technology, Information and
Communication, starting from online registration, data input and portfolio document
upload, CBT utilization, to assessment and ranking mechanisms using the
Application System are expected to be more effective, efficient and accountable.
This Technical Guideline is expected to be a reference for all levels involved
in the implementation of Sipenmaru Bersama Poltekkes Kemenkes Tanjungkarang
Tahun Akademik 202 3/2024.
.

Bandar Lampung, February 2023

Director
Health Polytechnic Ministry of Health
of Tanjungkarang,

Dewi Purwaningsih, S.SiT, M.Kes


196705271988012001

i
TABLE OF CONTENTS

Preface................................................................................................................................... i
Table of Contents.................................................................................................................... ii
I. Background................................................................................................................... 1
II. Goal............................................................................................................................... 1
1. General Purpose..................................................................................................... 1
2. Special Purpose...................................................................................................... 1
III. Legal Basis.................................................................................................................... 2
IV. Allocation....................................................................................................................... 3
V. Implementation Schedule.............................................................................................. 3
VI. Participant Requirements............................................................................................... 4
VII. Application Fee.............................................................................................................. 5
VIII. File Completeness......................................................................................................... 5
IX. Selection Stage.............................................................................................................. 6
X. Test Eyes....................................................................................................................... 6
XI. Registration Procedure.................................................................................................. 7
1. Registration............................................................................................................. 7
2. Scheme of Stages of Implementation of Sipenmaru Independent Line................... 8
XII. Re-register to be a freshman......................................................................................... 9
XIII. Amount of UKT persemester......................................................................................... 9

ii
NEW STUDENT ADMISSION SELECTION
SELF-GUIDED PATH
HEALTH POLYTECHNIC OF THE MINISTRY OF HEALTH TANJUNGKARANG

ACADEMIC YEAR 2023/2024

I. BACKGROUND
The purpose of Health Worker Education is to produce health workers who are professional
and competent in their fields. To achieve this, it is necessary to carry out institutional quality
assurance starting from the prospective student networking system, curriculum, certified
teaching staff, quality learning processes, adequate supporting infrastructure and education
management systems.

The selection of prospective students is carried out through the provisions of requirements and
a series of selections that must be met by prospective students. Selection activities are carried
out not only to measure ability but more focused on screening prospective students with the
best academic ability and non-academic achievement.

In the academic year 202 3/2024 Poltekkes Kemenkes Tanjungkarang held a selection of new
student admissions for the Independent Track for Level Transfer Programs, Professional
Nursing Programs and RKI Classes of Nursing STR Study Programs for foreign students. In
order for the implementation of new student admissions to run smoothly and be well
coordinated, it is necessary to issue a Guide for the Implementation of the Independent New
Student Admission Selection (Sipenmaru)

II. PURPOSE
1. General Purpose
Provide references in the implementation of the Sipenmaru Independent Line of Poltekkes
Kemenkes TanjungkarangAcademic Year 2023/2024.

2. Special Purpose
Provide references on:
a. Organizing and tasks of the Sipenmaru committee for the Independent Line of
Poltekkes Kemenkes TanjungkarangAcademic Year 2023/2024
b. Selection provisions for the Sipenmaru Independent Line of Poltekkes Kemenkes
TanjungkarangAcademic Year 2023/2024
c. Selection mechanism in Sipenmaru Independent Line Poltekkes Kemenkes
TanjungkarangAcademic Year 2023/2024
d. Financing for Sipenmaru activities for the Independent Line of Poltekkes Kemenkes
TanjungkarangAcademic Year 2023/2024
e. Reporting system for the implementation of Sipenmaru activities for the Independent
Line of Poltekkes Kemenkes TanjungkarangAcademic Year 2023/2024

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III. LEGAL BASIS
1. Law of the Republic of Indonesia Number 20 of 2003 concerning the National Education
System (State Gazette of the Republic of Indonesia of 2003 Number 78, Supplement to
the State Gazette of the Republic of Indonesia Number 4301);
2. Law of the Republic of Indonesia Number 36 of 2009 concerning Health (State Gazette of
the Republic of Indonesia of 2009 Number 144, Supplement to the State Gazette of the
Republic of Indonesia Number 4406);
3. Law of the Republic of Indonesia Number 12 of 2012 concerning Higher Education (State
Gazette of 2012 Number 158, Supplement to the State Gazette Number 5336);
4. Law of the Republic of Indonesia Number 36 of 2014 concerning Health Workers (State
Gazette of the Republic of Indonesia of 2014 Number 298, Supplement to the State
Gazette of the Republic of Indonesia Number 5607);
5. Government Regulation of the Republic of Indonesia Number 19 of 2005 concerning
National Standards of Education (State Gazette of the Republic of Indonesia of 2005
Number 41, Supplement to the State Gazette of the Republic of Indonesia Number 4496)
as last amended by Government Regulation Number 32 of 2013 concerning Amendments
to Government Regulation Number 19 of 2005 concerning National Standards of
Education (State Gazette of the Republic of Indonesia of 2013 Number 71, Supplement to
the State Gazette of the Republic of Indonesia Number 5410);
6. Government Regulation of the Republic of Indonesia Number 4 of 2014 concerning the
Implementation of Higher Education and Management of Higher Education (State Gazette
of the Republic of Indonesia of 2014 Number 16, Supplement to the State Gazette of the
Republic of Indonesia Number 5500);
7. Government Regulation of the Republic of Indonesia Number 64 of 2019 concerning
Types and Rates of Non-Tax Types of State Revenues Applicable to the Ministry of
Health (State Gazette of the Republic of Indonesia of 2019 Number 167, Supplement to
the State Gazette of the Republic of Indonesia Number 6386);
8. Presidential Regulation of the Republic of Indonesia Number 8 of 2012 concerning the
Indonesian National Qualifications Framework (KKNI) (State Gazette of the Republic of
Indonesia of 2012 Number 24);
9. Presidential Regulation of the Republic of Indonesia number 131 of 2013 concerning the
Determination of Disadvantaged Areas in 2015-2019 (State Gazette of the Republic of
Indonesia of 2015 Number 259);
10. Presidential Regulation Number 18 of 2021 concerning the Ministry of Health (Kemenkes)
11. Presidential Decree number 11 of 2020 concerning the Determination of the 2019 Corona
Virus Public Health Emergency (COVID-19);
12. Regulation of the Minister of Finance of the Republic of Indonesia Number 119 / PMK.05 /
2007 concerning Administrative Requirements in the Framework of Proposing and
Establishing Work Units of Government Agencies to Implement Financial Management of
Public Service Agencies;
13. Regulation of the Minister of Finance of the Republic of Indonesia Number
73/PMK.05/2008 concerning Procedures for Administration and Preparation of
Accountability Reports; Minister of Health Regulation number 71 of 2020;
14. Regulation of the Minister of Health of the Republic of Indonesia Number 36 of 2018
concerning the Classification of Health Polytechnics within the Health PPSDM Agency;
15. Regulation of the Minister of Education and Culture of the Republic of Indonesia Number
3 of 2022 concerning National Standards for Higher Education (State Gazette of the
Republic of Indonesia of 2022 Number 47);

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16. Regulation of the Minister of Health of the Republic of Indonesia Number 5 of 2022
concerning Organization and Work Procedures of the Ministry of Health (State Gazette of
the Republic of Indonesia of 2020 Number 1146);
17. Decree of the Minister of Education and Culture of the Republic of Indonesia Number
355 / E / O / 2012 concerning the Transfer of Development of Study Programs at the
Health Polytechnic of the Ministry of Health from the Ministry of Health to the Ministry of
Education and Culture;
18. Decree of the Minister of Health of the Republic of Indonesia Number
HK.02.03/I/3/03478/2013 concerning Guidelines for Organizing Selection for New Student
Admissions for Health Polytechnics of the Ministry of Health (Sipenmaru Poltekkes
Kemenkes).

IV. ALLOCATION
1. The maximum allocation of prospective students for each study program is determined by
the Directorate General of Health Workers based on the ratio of health care needs, taking
into account proposals from the poltekkes according to the ratio of lecturers to total students
of a maximum of 1: 30.

2. The allocation of prospective students accepted through the independent route is as follows: :

Tanjungkarang Poltekkes Student Admission Quota


Independent Track Academic Year 2023/ 2024

N
DEPARTEMENT COURSES QUOTA
O
1 Nursing Profession Ners 120
Bachelor of Applied
2 Environmental Health 50
Environtmental sanitation
Bachelor of Applied Medical
3 Health Analyst 50
Laboratory technology
Foreign
4 Nursing Bachelor of Applied Nursing
Student

V. SCHEDULE

NO Activities Schadule
1 Registration 10 - 31 Mei 2023
2 CBT Exam 5 - 8 Juni 2023
3 Assesment / Interview 9 - 10 Juni 2023 (RPL)
4 Ranking and Nomination 9 - 12 Juni 2023 (Ners & STR)
11 - 20 Juni 2023 (RPL)
5 Announcement of CBT selection result 13 Juni 2023
6 Registration and Implementation of Helath Test 13 - 16 Juni 2023
7 Health Test Nomination 19 Juni 2023
8 Final Graduation Announcement 20 Juni 2023
9 New Student Registration and Filing 21 - 28 Juni 2023
10 PKKMB Juli 2023
11 Lecture Implementation Juli 2023

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VI. PARTICIPANT REQUIREMENTS
1. Level Trasnsfer Program (Ladder Diploma 3 to Applied Bachelor Level)
a. Indonesian Citizen
b. Participants are graduates of Diploma III education who are in-line with the Applied
Bachelor Program to be followed. Participants upload the last diploma or certificate of
graduation and transcripts and participants have graduated status at PDDIKTI
c. Educational Background Requirements as follows:

 No Study program of Interest Educational requirements (Graduates)


1 Bachelor of Applied D3 Health Analyst / Medical Laboratory
Medical Laboratory Technology
Technology
2 Bachelor of Applied D 3 Environmental Health / Sanitation
Environmental Sanitation

d. The Origin Study Program has a minimum of Excellent accreditation in accordance with
the year of graduation.
e. For Department D.III Health Analyst / TLM to STr. TLM Minimum Working Period 2
Years (for regular graduates) And at the time of registration bring the Original Diploma,
lectures are held every Monday to Friday.
f. Physically and spiritually able, not partial and total color blind
g. Willing to follow the provisions of education during the educational process and if there
are courses / credits that have not been fulfilled, willing to take the current semester in
accordance with the guidelines for Level Transfer (Ajeng) Poltekkes Kemenkes
Tanjungkarang.
h. Participants can attach proof of training and / or have achievements at the district / city,
provincial, national or international levels.
i. RPL participants are required to fill out a self-evaluation based on the form provided
j. Participants can attach proof of service from the authorized official if they have worked.

2. Ners Professional Program


a. Graduates of study program D4 / Bachelor of Applied Nursing (from a study program at
least accredited B in Indonesia), for foreign graduates (The study program has
accreditation at least the level of B accreditation in Indonesia)
b. Able-bodied and not partial and total color blindness
c. Minimum height: male: 155 cm and female: 150 cm
d. Body Mass Index (BMI): Normal (18.5 – 25)
e. Nilai Test of English as Foreign Language (TOEFL) ITP minimal 425
f. Minimum grade point average (GPA) of 3.25

3. Bachelor of Applied Nursing (Foreign Students)


a. Foreign Nationals
b. Graduated from Senior High School / equivalent
c. Maximal graduation year 2021
d. Able-bodied, not color blind, physical condition does not interfere with duties as a health
worker. (The examination is carried out at the medical test stage)
e. Minimum height female 155 cm, male 160 cm

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VII. APPLICATION FEE
The registration fee for the self-track Sipenmaru is as follows:
1. Thelevel transfer program is Rp. 500.000,00 (Five hundred thousand rupiah
2. Theprogram of the Ners Profession is Rp. 500.000,00 (Five hundred thousand rupiah)
3. Bachelor of Applied Nursing (Foreign Students) of Rp. 700.000,00 (Seven hundred thousand
rupiah)

VIII.  FILE COMPLETENESS


1. Level Trasnsfer Program (Ladder Diploma 3 to Applied Bachelor Level)
a. Scan of diplomas and transcripts, which have been legalized
b. Scan of study program accreditation charter
c. Scan of the certificate of approval to attend education from the head of the work unit for
those who are already working
d. Scan of the certificate of approval to attend education from the husband / wife for those
who are married
e. Scan of the study assignment certificate for study assignment participants.
f. Scan of the statement letter able to bear the cost of education and comply with
education regulations
g. Those who have can submit a training charter and/or other in-service education
legalized by the head of the institution at the district, provincial, national, or international
level if they have.
h. Scan of a health certificate from a government doctor (government hospital, puskesmas)
including Height, not color blind
i. Attach the latest photo file size 4x6 cm with red background
j. Equalization Letter / Conversion of RPL Courses
k. KTP, Family Card, JKN/BPJS
      
Scans of the registration requirements file are uploaded to the system

2. Ners Professional Program


a. Scan of diplomas and transcripts, which have been legalized
b. Scan of study program accreditation charter
c. Scan of the certificate of approval to attend education from the head of the work unit for
those who are already working
d. Scan of the certificate of approval to attend education from the husband / wife for those
who are married
e. Scan of the study assignment certificate for study assignment participants.
f. Scan of the statement letter able to bear the cost of education and comply with
education regulations
g. Those who have can submit a training charter and/or other in-service education
legalized by the head of the institution at the district, provincial, national, or international
level if they have.
h. Scan of a health certificate from a government doctor (government hospital, Community
Health Center) including Height, not color blind
i. Attach the latest photo file size 4x6 cm with red background
j. Scan of TOEFL ITP certificate
k. KTP, Family Card, JKN/BPJS

Scans of the registration requirements file are uploaded to the system


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3. Bachelor of Applied Nursing (Foreign Students)
a. Scan of diplomas and grade lists, which have been legalized
b. Scan of certificate of consent to attend education from parents
c. Scan of the certificate of approval following education from the relevant agency of the
sending country
d. Scan of a statement letter willing to follow education and obey all education regulations
e. For those who have, can submit a training charter and / or other in-service education
legalized by the head of the institution at the district, provincial, national, or international
level if they have.
f. Scan of a health certificate from a government doctor (government hospital, Community
Health Center) including Height (TB), not color blind
g. Scan of Certificate of good behavior from the relevant agency of the prospective
participant's country of origin
h. Attach the latest photo file size 4x6 cm with red background
i. Scan of residence documents, participant's passport

IX.  SLECTION STAGES


The selection that will be carried out includes:
1. Selection phase I (Written Test)
2. Selection phase II (Interview credit conversion assessment according to the Guidelines
for Transfer of Poltekkes Level of the Ministry of Health Tanjungkarang)
3. Selection stage III Health test (Physical and Spiritual Health)

X.  EXAM MATERIALS
1. Level Trasnsfer Program (Ladder Diploma 3 to Applied Bachelor Level)
1.1 Bachelor of Science Applied Medical Laboratory Technology

No Exam Materials
1 Bacteriology
2 Clinical Chemistry
3 Parasitology
4 Immunoserology
5 Hematology
6 Toksikology
7 Cytohistotechnology

1.2 Bachelor of Science Applied Environtmental Sanitation

No Exam Materials
1 Water Health
2 Soil Health
3 Disease Vector Control
4 Air Health
5 Food and Beverage Health
6 Community Empowerment

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2. Ners Professional Program

No Mata Uji
1 Keperawatan Medikal Bedah
2 Keperawatan Maternitas
3 Keperawatan Anak
4 Keperawatan Jiwa
5 Keperawatan Gerontik
6 Keperawatan Gadar
7 Keperawatan Komunitas dan keluarga
8 Manajemen Keperawatan

3. Bachelor of Applied Nursing (Foreign Students)


The CBT Examination material for Bachelor of Applied Nursing for Foreign students consists
of test subjects:
a) Marhematics
b) English
c) Science (Biology, Physics and Chemistry)

XI. REGISTRATION PROCEDURES


a. Registration
i. General Terms
Before the selection of new students for the independent path of the Health
Polytechnic of the Ministry of Health Tanjungkarang T.A 2023/2024, ICT infrastructure
needs to be prepared from the beginning by involving partner banks and online
registration access service providers. Applications supporting the registration process
include: (1) Application for the management of the official website of the Health
Polytechnic CBT of the Ministry of Health of Tanjungkarang, (2) Online Registration
Application for the Health Polytechnic of the Ministry of Health of Tanjungkarang :
https://pmb.poltekkes-tjk.ac.id

ii. CBT Assesment Mechanism


1) Every participant of Sipenmaru CBT Health Polytechnic of the Ministry of Health
Tanjungkarang is required to take a computer-based written test
2) Ranking is a sequence of values obtained by all participants from highest to
lowest.
3) Nominations are determined by the director of the Health Polytechnic of the
Tanjungkarang Ministry of Health based on grade ratings and can consider other
determining components.
4) The announcement of the results of the assessment nomination is adjusted to the
quota of each study program and can be increased by a maximum of 50% of the
CBT quota set.
5) Document verification is carried out by the Local Committee on participants who
have passed the assessment nomination.
6) If a discrepancy is found between the data and the document or falsification of the
uploaded document, the participant is considered void.
7) The results of document verification are used in determining the final selection
results of CBT

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iii. Assesment / Interfiew
Assesment / Interview carried out on applicants for the Level Transfer Program in
accordance with the applicable Level Transfer Program assessment provisions

iv. Health Test and Psychological Test


Participants who are declared to have passed the nomination are required to conduct a
Medical Test to obtain comprehensive information on the health condition of
prospective participants

v. Final Graduation
1. The final graduation determination is based on the results of the assessment of
CBT test results, Interview/Assessment results (for Level Transfer Program) and
the results of medical tests and/or other tests through a final determination meeting
involving the Committee.
2. Final graduation is determined by the Committee.

vi. Announcement of Accepted New Student Candidates


The final graduation of the independent path sipenmaru was announced by the
Committee through an online application system to each participant and a mirror
website page of the Health Polytechnic of the Ministry of Health Tanjungkarang

vii. Registration for Prospective New Student Accepted


Prospective new students who are accepted through the independent route must re-
register directly to the Health Polytechnic of the Ministry of Health Tanjungkarang. If
by the deadline for registration the number of applicants is less than the specified
allocation amount, the deficiency is met from prospective reserves while considering
the guaranteed quality of student raw input.

b. Scheme of Stages of Implementation of Sipenmaru Independent Line


The implementation of the Sipenmaru Independent Line in general can be described in
several stages as shown below:

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STAGES SELF-GUIDED PATH
POLTEKKES KEMKES TANJUNGKARANG IN 2023/2024

Interview/Assessment (Ajeng Only)


PREPARATION

Policy, Juknis,

Level Transfer Class


IMPLEMENTATION
Implementation,
Application Computer-based test (CBT)
System, Announcement of
Socialization Interview/Assessment Results

Valuation
Rating Health Test
(Physical and Spiritual)
Nomination

STR Study Program &; Ners


Verification of Health Test

Profession
Results
Announcement of Nomination
Results

REGISTRATION
AND
FILING

XII. RE-APPLY TO BECOME A FRESHMAN


Technical re-registration / registration will be announced on the Health Polytechnic website of the
Ministry of Health Tanjungkarang along with the announcement of passing the health test.

XIII. AMOUNT OF SINGLE TUITION PER SEMESTER

TABLE OF SINGLE TUITION PER SEMESTER


H
(SK DIREKTUR POLTEKKES KEMENKES TANJUNGKARANG NO. HK.02.03/I.2/2022/2022)

NO COURSES APPLIED BACHELOR PROFESSION


(Rp) (Rp)
1 NURSING 4.800.000 9.010.000

2 ENVIRONTMENTAL HEALTH 5.470.000 -

3 MEDICAL LABORATORY 5.992.000 -


TECHNOLOGY

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ATTACHMENT

ATTACHMENT 1
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LETTER PERAPPROVAL TO ATTEND EDUCATION
FROM THE HEAD OF THE WORK UNIT

The Undersigned:
Name : .............................................................................................................
Employee ID Number : .............................................................................................................
Position : .............................................................................................................
Workplace Instancy : .............................................................................................................

is the Direct Supervisor of:


Name : .............................................................................................................
Employee ID Number : .............................................................................................................
Position : .............................................................................................................
Workplace Instancy : .............................................................................................................

Hereby give approval to attend education in the Level Transfer Program (Ajeng) of the Applied
Environmental Sanitation/Medical laboratory technology*) Study Program, Health Polytechnic,
Ministry of Health, Tanjungkarang which will start in the 2023/2024 Academic Year.

Thus this letter of consent is actually made to be used properly.

..............................................,.......................
Direct Supervisor,

Materai

................................................

Note:
*) Unnecessary strikethroughs

Attacment 2

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LETTER OF APPROVAL TO ATTEND EDUCATION
FROM SPOUSE

I am the undersigned:

Name : .............................................................................................................
Address : .............................................................................................................
: .............................................................................................................
Place/Date of Birth : .............................................................................................................
Spouse of : .............................................................................................................

Hereby declares that I give consent to my Husband/Wife*)


named ........................................................................ to take part in the Level Transfer Program
(Ajeng) in the Applied Bachelor of Environmental Sanitation/Medical Laboratory Technology Study
Program*) of the Health Polytechnic of the Ministry of Tanjungkarang which will start in the 2023/2024
Academic Year.

Thus this letter of consent is actually made to be used properly.

..............................................,.......................
Statement Maker,

Materai

................................................

Note:
*) Unnecessary strikethroughs

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Attachment 3

STATEMENT LETTER
WILLING TO BEAR THE COST OF EDUCATION AND
OBEYING EDUCATION REGULATIONS

I am the undersigned:

Name : .............................................................................................................
Address : .............................................................................................................
: .............................................................................................................
Place/Date of Birth : .............................................................................................................
Employee ID Number : .............................................................................................................
Workplace Instancy : .............................................................................................................

Stating that I am able to bear the cost of education and obey the education regulations during the
education process at the Health Polytechnic of the Tanjungkarang Ministry of Health and if in the
future it turns out that I am unable to bear the cost of education and I do not obey the education
regulations then I am willing to accept sanctions in accordance with the applicable laws and
regulations at the Health Polytechnic of the Ministry of Health Tanjungkarang.

Thus this affidavit is actually made to be used properly.

..............................................,.......................
Pembuat Pernyataan,

Materai

................................................

Note:
*) Required for Participants with Civil Servant status
ATTACHMENT 4

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LETTER OF APPROVAL TO ATTEND EDUCATION
FROM PARENTS

The Undersigned:
Nama/Name : .............................................................................................................
Alamat/ Address : .............................................................................................................
: .............................................................................................................
Tempat/Tanggal Lahir
Place/Date of Birth : .............................................................................................................
Kebangsaan/Nationality : .............................................................................................................

Are The Parents of:


Nama/Name : .............................................................................................................
Alamat/Address : .............................................................................................................
: .............................................................................................................
Tempat/Tanggal Lahir
Place/Date of Birth : .............................................................................................................
Kebangsaan/Nationality : .............................................................................................................

Hereby gives approval to attend education in the International Class of the Health Polytechnic Applied
Undergraduate Program in Nursing of the Ministry of Health Tanjungkarang, Lampung, Indonesia
which will start in the 2023/2024 Academic Year. Thus this letter of consent is actually made to be
used properly.

Thus this letter of consent is actually made to be used properly.

..............................................,.......................
Statement Maker,

Seal

................................................

ATTACHMENT 5

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STATEMENT LETTER WILLING
TO OBEY EDUCATION REGULATIONS

I am Undesignedr:

Nama/Name : ............................................................................................................
Alamat/Address : ............................................................................................................
: ............................................................................................................
Tempat/Tanggal Lahir
Place/Date of Birth : ............................................................................................................
NIP/Employee ID Number : ............................................................................................................
Instansi Tempat kerja
Workplace Agency : ............................................................................................................

Stating that I am able to obey the applicable regulations while participating in the education process
at the Health Polytechnic of the Tanjungkarang Ministry of Health and if in the future it turns out to
violate these regulations, then I am willing to accept sanctions in accordance with the applicable laws
and regulations at the Health Polytechnic of the Ministry of Health Tanjungkarang, Lampung,
Indonesia.

Thus this affidavit is actually made to be used properly.

..............................................,.......................
Statement Maker,

Seal

................................................

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