SPJ Persalinan Jampersal 2013

CARA PENGHITUNGAN REMUNERASI JAMPERSAL
BAHAN SPJ
No. Poli/Polindes Vol. Jaspel Jasa Sarana Retribusi Jumlah Klaim Klaim Jaspel Dinkes Jaspel Langsung Jaspel Tak Langsung JUMLAH
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
PERTOLONGAN PESALINAN
I Persalinan Puskesmas
a. Persalinan Normal 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
b. Persal Dgn Tind. Emerg. Dsr 2 633,750 16,250 650,000 1,300,000 1,267,500 31,688 1,014,000 190,125 31,688 1,267,500
c. Pra Rujukan Oleh Puskesmas 1 100,000 - 100,000 100,000 100,000 5,000 60,000 31,000 4,000 100,000
d. Transport rujukan 1 40,000 20,000 60,000 60,000 40,000 1,200 36,000 2,000 800 40,000
e. Tindakan Pasca Persalinan 1 150,000 - 150,000 150,000 150,000 4,500 135,000 7,500 3,000 150,000
II Persalinan Polindes
1 Polindes .......................
a. Pertolongan Persalinan 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 2 17,500 32,500 50,000 100,000 35,000 1,750 21,000 10,850 1,400 35,000
e. Pasang Implant 2 17,500 32,500 50,000 100,000 35,000 1,750 21,000 10,850 1,400 35,000
f. Suntik KB 5 3,500 6,500 10,000 50,000 17,500 875 10,500 5,425 700 17,500
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
2 Polindes .......................
a. Pertolongan Persalinan 487,500 12,500 500,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
3 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
4 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
5 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
6 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
9 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
10 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
11 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
12 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
13 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
14 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
15 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
16 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
17 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
18 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
19 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
20 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
21 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
22 Polindes .......................
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
23 Polindes .......................
BAHAN SPJ
2,5% - 5% 60% s/d 97,5% Remun 15 - 31% Pimp. 1.5% - 4%
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 20 16,706,250 2,003,750 18,710,000 4,860,000 4,570,000 95,513 4,003,125 379,625 91,738 4,570,000
SUDAH DITERIMA DARI : PENGGUNA ANGGARAN DINAS KESEHATAN KABUPATEN BOJONEGORO
UNTUK PEMBAYARAN : JASA PELAYANAN LANGSUNG ( RAWAT JALAN BAYAR / RAWAT INAP / JAMKESDA / ASKES)
BAGIAN BULAN : MARET 2013
PUSKESMAS : UPAYA SEHAT
BEBAN ANGGARAN : APBD KABUPATEN BOJONEGORO
TAHUN ANGGARAN : 2013
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
JUMLAH UANG : Rp. 4,003,125
TERBILANG : Delapan juta lima ratus tujuh puluh sembilan ribu dua puluh lima rupiah
dengan rincian :
Jaspel Langsung
Dinkes Tanda
No. Nama / Golongan Jabatan Jasa Pelayanan PPH Diterima
1.5% s/d 5% Tangan
(60%s/d 97,5%)
1 2 3 4 5 6 7 8 9
1 dr. Anugrah Ilahi Kepala Rp. 1,852,500 Rp. 46,313 Rp. 1,404,000 Rp. 70,200 Rp. 1,333,800
Gol. III/d Puskesmas
2 Ririn Bidan Rp. 2,437,500 Rp. 36,563 Rp. 2,315,625 Rp. 115,781 Rp. 2,199,844
Gol. III/c
ANC Rp. 390,000 Rp. 19,500 Rp - Rp - Rp -
PNC Rp. 487,500 Rp. 24,375 Rp - Rp - Rp -
Pasang IUD Rp. 35,000 Rp. 1,750 Rp. 21,000 Rp. 1,050 Rp. 19,950
Pasang Implant Rp. 35,000 Rp. 1,750 Rp. 21,000 Rp. 1,050 Rp. 19,950
Suntik KB Rp. 17,500 Rp. 875 Rp -
Pra Rujukan Rp. 100,000 Rp. 5,000 Rp. 60,000 Rp. 3,000 Rp. 57,000
3 Indah Dewi Buana Bidan Rp. 3,900,000 Rp. 58,500 #REF! #REF!
Gol. II/d
ANC Rp. 195,000 Rp. 9,750 Rp - Rp -
PNC Rp. 292,500 Rp. 14,625 Rp - Rp -
Pasang IUD Rp. 35,000 Rp. 1,750 #REF! #REF!
Pasang Implant Rp. 35,000 Rp. 1,750 #REF! #REF!
Suntik KB Rp. 17,500 Rp. 875 Rp - Rp -
Pra Rujukan Rp. 100,000 Rp. 5,000 Rp - Rp -
Transport Rujukan Rp. 18,000 Rp. 540 Rp. 18,000 Rp. 18,000
4 Muanam Rp. 18,000 Rp. 540 Rp. 18,000 Rp. 18,000
JUMLAH Rp. 9,966,000 Rp. 229,455 #REF! Rp. 191,081 #REF!
Bojonegoro, - - 2013
Penanggungjawab Pengelola Jasa Pelayanan
Kepala Pusk. Upaya Sehat
AGUS PUTRA PETIR

dr. ANUGRAH ILAHI NIP. 19780123 200501 1 003
NIP. 19810506 200804 1 013
Mengetahui/setuju dibayar Pejabat Pelaksana Teknik Lunas dibayar tgl……………….

KPA Kegiatan Penyediaan Biaya Kegiatan ( PPTK ) Bendahara Pengeluaran Pembantu
Operasional dan Pemeliharaan
BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. SRI WIDJIATI, SE.

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP. 19631201 200112 2 001
KPA Kegiatan Penyediaan Biaya Kegiatan ( PPTK ) Bendahara Pengeluaran Pembantu
BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. SRI WIDJIATI, SE.

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP. 19631201 200112 2 001
UNTUK PEMBAYARAN : JASA PELAYANAN TAK LANGSUNG REMUNERASI PUSKESMAS
( RAWAT JALAN BAYAR / RAWAT INAP / JAMKESDA / ASKES)
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
JUMLAH UANG : Rp. 379,625
TERBILANG : Satu Juta Tiga Ratus Tiga Puluh Ribu Rupiah
dengan rincian :
No. Nama / Golongan Jabatan Remunerasi PPH Diterima Tanda Tangan
1 2 3 5 7 8 9
1 dr. Anugrah Ilahi Kepala Rp - Rp -
Gol. III/d Puskesmas
2 Agus Putra Petir Perawat Rp - Rp -
Gol. III/c
3 Indah Dewi Buana Bidan Rp -

Gol. II/d
4 Endra Harimurti Pelk. Tata Rp -
Gol. II/a Usaha
5 M. Rendianto Perawat Rp -
Gol. -
6 Bumil Risti Bidan Rp -
Gol. -
JUMLAH Rp - Rp - Rp -
Penanggungjawab
Kepala Pusk. Upaya Sehat
Pengelola Jasa Pelayanan
dr. ANUGRAH ILAHI

AGUS PUTRA PETIR
NIP. 19810506 200804 1 013
NIP. 19780123 200501 1 003
Mengetahui/setuju dibayar Lunas dibayar tgl……………….

KPA Kegiatan Penyediaan Biaya Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Operasional dan Pemeliharaan Kegiatan ( PPTK )
SRI WIDJIATI, SE.

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. NIP. 19631201 200112 2 001
NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004
UNTUK PEMBAYARAN : JASA PELAYANAN TAK LANGSUNG REMUNERASI UNSUR PIMPINAN
( RAWAT JALAN BAYAR / RAWAT INAP / JAMKESDA / ASKES)
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Tiga Ratus Tiga Puluh Ribu Rupiah
dengan rincian :
Unsur
No. Nama / Golongan Jabatan Pimpinan PPH Diterima Tanda Tangan
1 2 3 5 7 8 9
1 Agus Putra Petir Perawat
Gol. III/c Koord.
2 Indah Dewi Buana Bidan Koord.

Gol. II/d
3 Endra Harimurti Kepala TU
Gol. II/a
JUMLAH Rp - Rp - Rp -
Penanggungjawab
Kepala Pusk. Upaya Sehat Pengelola Jasa Pelayanan
dr. ANUGRAH ILAHI AGUS PUTRA PETIR

NIP. 19810506 200804 1 013 NIP. 19780123 200501 1 003
Lunas dibayar tgl……………….

Mengetahui/setuju dibayar Bendahara Pengeluaran
KPA Kegiatan Penyediaan Biaya Pejabat Pelaksana Teknik Pembantu
Operasional dan Pemeliharaan Kegiatan ( PPTK )
SRI WIDJIATI, SE.

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. NIP. 19631201 200112 2 001
NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004
PUSKESMAS NGASEM BULAN MARET 2013
BAHAN SPJ
No. Poli/Polindes Vol. Jaspel Jasa Sarana Retribusi Jumlah Klaim Klaim Jaspel Dinkes Jaspel Langsung60% s/d 97,5% Jaspel Tak Langsung JUMLAH
2,5% - 5% Dokter Bidan Remun 15 - 31%Pimp. 1.5% - 4%
a. Persalinan Normal
b. Persal Dgn Tind. Emerg. Dsr
c. Pra Rujukan Oleh Puskesmas
f. Suntik KB
b. A N C
c. P N C
d. Transport rujukan 40,000 20,000 60,000 - - - - - - -
e. Tindakan Pasca Persalinan 150,000 - 150,000 - - - - - - -
1 Polindes Ngasem
a. Pertolongan Persalinan
Suci 9 487,500 12,500 500,000 4,500,000 4,387,500 65,813 4,168,125 87,750 65,813 4,387,500
b. A N C
dr.Agust 19 19,500 500 20,000 380,000 370,500 18,525 33,345 114,855 14,820 181,545
Suci 19 19,500 500 20,000 380,000 370,500 188,955 188,955
dr.Vera 21 19,500 500 20,000 420,000 409,500 20,475 36,855 126,945 16,380 200,655
Suci 21 19,500 500 20,000 420,000 409,500 208,845 208,845
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Suci 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Suci 2 19,500 500 20,000 40,000 39,000 19,890 19,890
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
Suci 17,500 32,500 50,000 - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Suci 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
2 Polindes Dukohkidul
Sri Pujiati 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Sri Pujiati 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Sri Pujiati 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
3 Polindes Ngadiluwih
Rina Pangestu W. 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Rina Pangestu W. 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Rina Pangestu W. 5 19,500 500 20,000 100,000 97,500 49,725 49,725
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Rina Pangestu W. 2 19,500 500 20,000 40,000 39,000 19,890 19,890
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
4 Polindes Sendangharjo
b. A N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Elis 4 19,500 500 20,000 80,000 78,000 39,780 39,780
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Elis 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Elis 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Elis 5 19,500 500 20,000 100,000 97,500 49,725 49,725
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
5 Pustu Trenggulunan
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C
dr.Agust 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Lisyati 12 19,500 500 20,000 240,000 234,000 119,340 119,340
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Lisyati 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Lisyati 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Lisyati 2 19,500 500 20,000 40,000 39,000 19,890 19,890
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Yuni 7 19,500 500 20,000 140,000 136,500 69,615 69,615
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Yuni 5 19,500 500 20,000 100,000 97,500 49,725 49,725
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Misrotun 6 19,500 500 20,000 120,000 117,000 59,670 59,670
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Misrotun 5 19,500 500 20,000 100,000 97,500 49,725 49,725
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Misrotun 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Misrotun 5 19,500 500 20,000 100,000 97,500 49,725 49,725
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
dr.Vera 17,500 32,500 50,000 - - - - - - -
Misrotun 17,500 32,500 50,000 - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Misrotun 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Misrotun 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
9 Polindes Mediyunan
Santi 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Santi 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Santi 1 19,500 500 20,000 20,000 19,500 9,945 9,945
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Santi 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Santi 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Santi 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
10 Polindes Bandungrejo
Fajrin 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Fajrin 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Fajrin 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Fajrin 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Fajrin 2 19,500 500 20,000 40,000 39,000 19,890 19,890
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 196 4,561,000 149,000 4,710,000 15,380,000 14,958,000 338,400 293,220 12,776,580 1,243,980 305,820 14,958,000
SUDAH DITERIMA DARI PENGGUNA ANGGARAN DINAS KESEHATAN KABUPATEN BOJONEGORO
UNTUK PEMBAYARAN JASA PELAYANAN LANGSUNG (PERSALINAN JAMPERSAL)
BAGIAN BULAN MARET
PUSKESMAS NGASEM
BEBAN ANGGARAN APBD KABUPATEN BOJONEGORO
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
JUMLAH UANG Rp. 13,069,800
TERBILANG Tiga Belas Juta Enam Puluh Sembilan Ribu Delapan Ratus Rupiah
dengan rincian
Jaspel Langsung
Dinkes Tanda
1.5% s/d 5% Tangan
(60%s/d 97,5%)
1 2 3 4 5 6 7 8 9
1 dr.Agust Fariono Kapus 1

Gol.IV/a
ANC Rp 1,189,500 Rp. 59,475 Rp. 107,055 Rp. 16,058 Rp. 90,997
PNC Rp 527,300 Rp. 26,325 Rp. 47,385 Rp. 7,108 Rp. 40,277
Suntik KB Rp 7,000 Rp. 350 Rp. 630 Rp. 95 Rp. 536
dr.Tri Vera
2 Dokter 2
Handayani
Gol.III/b
ANC Rp 1,053,000 Rp. 52,650 Rp. 94,770 4,739 Rp. 90,031
PNC Rp 468,000 Rp. 23,400 Rp. 42,120 2,106 Rp. 40,014
Suntik KB Rp 14,000 Rp. 700 Rp. 1,260 63 Rp. 1,197
3 Lisyati Bidan 3
Gol.II/c
Persalinan Normal Rp. 2,437,500 Rp. 36,563 Rp. 2,315,625 Rp. 2,315,625
ANC Rp. 198,900 Rp. 198,900
PNC Rp. 49,725 Rp. 49,725
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Rina Pangestu W Bidan 4
Gol.II/c
Pertolongan Persalinan Rp 487,500 Rp. 7,313 Rp. 463,125 Rp. 463,125
Persal dg tind
emergn.Dsr
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 19,890 Rp. 19,890
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
5 Yuni Susetyawati Bidan 5
Gol.-
Persal dg tind
emergn.Dsr
Pertolongan Persalinan Rp. 975,000 Rp. 14,625 Rp. 926,250 Rp. 926,250
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 119,340 Rp. 119,340
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
6 Dwi Wijayanti Bidan 6
Gol.-
Pertolongan Persalinan
Persal dg tind
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
7 Suci Mukti Bidan 7
Gol.-
Pertolongan Persalinan Rp. 4,387,500 Rp. 65,813 Rp. 4,168,125 Rp. 4,168,125
Persal dg tind
emergn.Dsr
ANC Rp. 397,800 Rp. 397,800
PNC Rp. 39,780 Rp. 39,780
Pasang IUD
Pasang Implant
Suntik KB Rp. 1,785 Rp. 1,785
Pra Rujukan
8 Sri Pujiati,A.mD.Keb Bidan 8
Gol.II/b
ANC Rp. 79,560 Rp. 79,560
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
9 Misrotun Bidan 9
Gol.III/c
Pertolongan Persalinan Rp. 1,462,500 Rp. 21,938 Rp. 1,389,375 69,469 Rp. 1,319,906
Persal dg tind
emergn.Dsr
Pra Rujukan
ANC Rp. 109,395 5,470 Rp. 103,925
PNC Rp. 79,560 3,978 Rp. 75,582
Pasang IUD
Pasang Implant
Suntik KB Rp. 5,355 290 Rp. 5,065
10 Elis D,A.Md.Keb Bidan 10
Gol.II/d
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 79,560 Rp. 79,560
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
11 Santi Bidan 11
Gol.-
ANC Rp. 39,780 Rp. 39,780
PNC Rp. 79,560 Rp. 79,560
Pasang IUD
Pasang Implant
Pra Rujukan
Transport Rujukan
12 Fajrin Bidan 12
Gol.-
Persal dg tind Rp -
emergn.Dsr
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 39,780 Rp. 39,780
Pasang IUD Rp -
Pasang Implant
Suntik KB Rp -
Pra Rujukan Rp -
Transport Rujukan
JUMLAH Rp. 14,958,000 Rp. 338,400 Rp. 13,069,800 Rp. 109,375 Rp. 12,960,425
Penanggungjawab Bojonegoro,03 April 2013

Kepala UPTD Puskesmas Ngasem Pengelola Jasa Pelayanan
dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
dibayar
KPA Kegiatan Pejabat Pelaksana Teknik
KPA Kegiatan Penyediaan Biaya Operasional Bendahara Pengeluaran Pembantu
Penyediaan Biaya Kegiatan ( PPTK )
Operasionaldan
danPemeliharaan
Pemeliharaan
BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

RUDI EKO PRASETYO, S.Psi. NIP. 19631201 200112 2 001
NIP. 19660809 198803 1 010
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
(PERSALINAN JAMPERSAL)
BAGIAN BULAN : MARET
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Dua Ratus Empat Puluh Tiga Ribu Sembilan Ratus
Delapan Puluh Rupiah
dengan rincian :
1 2 3 5 7 8 9
1 dr.H.M.Agust Fariono,IV/a Kapus Rp 39,589 Rp. 5,938 Rp. 33,651 1
2 Dhuriyati,A.Md.Keb, III/c Bidan Rp 28,977 Rp. 1,449 Rp. 27,528 2
3 dr.Tri Vera Handayani,III/b Dokter Rp 39,589 Rp. 1,979 Rp. 37,610 3
4 Isnani'atin,III/b TU Rp 27,753 Rp. 1,388 Rp. 26,365 4
5 Misrotun,A.Md.Keb,III/c Bidan Rp 28,977 Rp. 1,449 Rp. 27,528 5
6 Utuh Sujadi,S.Kep,III/b Perkor Rp 32,650 Rp. 1,633 Rp. 31,017 6
7 Bobby Analis Rp. 1,286 Rp. 24,426 7
Marcandra,A.Md.AK,III/a Rp 25,712
8 M.Kusnindar,II/d Perawat Rp 8,979 Rp. 8,979 8
9 Sunanik,A.Md.Keb,III/a Bidan Rp 33,875 Rp. 1,694 Rp. 32,181 9
10 Elis Dianawati,A.Md.Keb,II/d Bidan Rp 25,712 Rp. 25,712 10
11 Yulianto S.A.Md.Gz,II/c Nutrisionis Rp 20,815 Rp. 20,815 11
12 Sri Pujiati,A.Md.Keb,II/c Bidan Rp 25,712 Rp. 25,712 12
13 Lisyati,A.Md.Keb,II/c Bidan Rp 25,712 Rp. 25,712 13
14 Hj.Sri Endang S.A.Md.Keb,II/c Bikor Rp. 31,426
14
Rp 31,426
15 Rina Pangestu W.A.Md.Keb,II/b Bidan Rp. 25,712 15
Rp 25,712
16 Munari,IIc Sopir Rp 14,285 Rp. 14,285 16
17 Drg.Dwi Risna Dokter Gigi Rp 30,202 Rp. 30,202 17
18 Santi,A.Md.keb Bidan Rp 28,977 Rp. 28,977 18
19 Suci Mukti,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 19
20 Yuni S,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 20
21 Fajrin Isna BA,.md.Keb Bidan Rp 25,712 Rp. 25,712 21
22 Dwi Wijayanti,a.Md.Keb Bidan Rp 25,712 Rp. 25,712 22
23 Erwina S,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 23
24 Erwin S,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 24
25 Indra A.Md.Kep Perawat Rp 25,712 Rp. 25,712 25
26 Nurin N,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 26
27 Arifin,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 27
28 Musrianik,A.md.Kep Perawat Rp 25,712 Rp. 25,712 28
29 Faried,A.Md.Kep Perawat Rp 26,937 Rp. 26,937 29
30 Puguh,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 30
31 Rina Dhatul,A.Md.Keb Perawat Rp 25,712 Rp. 25,712 31
32 Pujo Santoso,A.md.Kep Perawat Rp 25,712 Rp. 25,712 32
33 M.Iksanto Admin Rp 12,244 Rp. 12,244 33
34 Ika Arista Admin Rp 14,693 Rp. 14,693 34
35 Puji H,A.Md.Kep Perawat Rp 26,937 Rp. 26,937 35
36 Dwi Indah,S.Kom Admin Rp 21,223 Rp. 21,223 36
37 Tutik,S.Kom Admin Rp 21,223 Rp. 21,223 37
38 Yudianto,SH Apotek Rp 17,958 Rp. 17,958 38
39 Agung Yudha Admin Rp 15,509 Rp. 15,509 39
40 Pujianto,.AM.d.Kep Perawat Rp 26,937 Rp. 26,937 40
41 Yuni Dwi,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 41
42 Windy Agustin,.Amd.Keb Bidan Rp 25,712 Rp. 25,712 42
43 Anugerah S,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 43
44 Siti Indha,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 44
45 Erna,A.Md.Keb Bidan Rp 25,712 Rp. 25,712 45
46 Windy W,A.Md.keB Bidan Rp 25,712 Rp. 25,712 46
47 Suci Hardini,A.md.Kep Perawat Rp 25,712 Rp. 25,712 47
48 Ongky A,.AM.d.Kep Perawat Rp 25,712 Rp. 25,712 48
49 Nurmalita,A.Md.Kep Perawat Rp 25,712 Rp. 25,712 49
JUMLAH Rp. 1,243,980 Rp. 16,816 Rp. 1,227,164

NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju dibayar
KPA Kegiatan Penyediaan Biaya Operasional Lunas dibayar tgl……………….
dan Pemeliharaan Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Kegiatan ( PPTK )

NIP. 19660809 198803 1 010 RUDI EKO PRASETYO, S.Psi. NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
BAGIAN BULAN : MARET
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Tiga Ratus Lima Ribu Delapan Ratus Dua Puluh Rupiah
dengan rincian :
No Unsur
. Nama / Golongan Jabatan Pimpinan PPH Diterima Tanda Tangan
1 2 3 5 7 8 9
1 dr.H.M.Agust Fariono ,IV/a Kapus Rp 78,320 Rp. 11,748 Rp. 66,572 1
3 Isnaniatin,III/b TU Rp 55,943 Rp. 2,797 Rp. 53,146 3
4 Utuh Sujadi,s.Kep ,III/b Perkor Rp 48,484 Rp. 2,424 Rp. 46,060 4
5 Hj.Sri Endang S.A.Md.Keb, II/c Bikor
Rp. 55,942 5
Rp 55,942
JUMLAH Rp. 305,820 Rp. 20,326 Rp. 285,494


NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya Operasional Pejabat Pelaksana Teknik Lunas Dibayar Tgl…………..
dan Pemeliharaan )Kegiatan (PPTK' Bendahara Pengeluaran Pembantu
BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI,SE

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN APRIL 2013
BAHAN SPJ
Elis 2 487,500 12,500 500,000 1,000,000 975,000 24,375 780,000 146,250 24,375 975,000
Santi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Dwi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
Yuni 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
dr.Vera 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
Santi 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
f. Suntik KB
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Rina 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Yuni 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Elis 3 19,500 500 20,000 60,000 58,500 29,835 29,835
Dwi 2 19,500 500 20,000 40,000 39,000 19,890 19,890
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Elis 1 19,500 500 20,000 20,000 19,500 9,945 9,945
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Dwi 2 19,500 500 20,000 40,000 39,000 19,890 19,890
1 Polindes Ngasem
Suci 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Suci 6 19,500 500 20,000 120,000 117,000 59,670 59,670
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Suci 10 19,500 500 20,000 200,000 195,000 99,450 99,450
c. P N C
dr.Agust 9 19,500 500 20,000 180,000 175,500 8,775 15,795 54,405 7,020 85,995
Suci 9 19,500 500 20,000 180,000 175,500 89,505 89,505
dr.Vera 17 19,500 500 20,000 340,000 331,500 16,575 29,835 102,765 13,260 162,435
Suci 17 19,500 500 20,000 340,000 331,500 169,065 169,065
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
Suci 17,500 32,500 50,000 - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 2 17,500 32,500 50,000 100,000 35,000 1,750 3,150 10,850 1,400 17,150
Suci 2 17,500 32,500 50,000 100,000 35,000 17,850 17,850
dr.Vera 2 17,500 32,500 50,000 100,000 35,000 1,750 3,150 10,850 1,400 17,150
Suci 2 17,500 32,500 50,000 100,000 35,000 17,850 17,850
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Suci 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
dr.Vera 4 3,500 6,500 10,000 40,000 14,000 700 1,260 4,340 560 6,860
Suci 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
a. Pertolongan Persalinan 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
Sri Pujiati 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Sri Pujiati 1 19,500 500 20,000 20,000 19,500 9,945 9,945
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Sri Pujiati 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Sri Pujiati 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Sri Pujiati 7 19,500 500 20,000 140,000 136,500 69,615 69,615
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Rina Pangestu W. 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Rina Pangestu W. 1 19,500 500 20,000 20,000 19,500 9,945 9,945
dr.Vera 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Rina Pangestu W. 1 19,500 500 20,000 20,000 19,500 9,945 9,945
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Rina Pangestu W. 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Rina Pangestu W. 4 19,500 500 20,000 80,000 78,000 39,780 39,780
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Lisyati 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Lisyati 5 19,500 500 20,000 100,000 97,500 49,725 49,725
c. P N C
dr.Agust 20 19,500 500 20,000 400,000 390,000 19,500 35,100 120,900 15,600 191,100
Lisyati 20 19,500 500 20,000 400,000 390,000 198,900 198,900
dr.Vera 28 19,500 500 20,000 560,000 546,000 27,300 49,140 169,260 21,840 267,540
Lisyati 28 19,500 500 20,000 560,000 546,000 278,460 278,460
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Yuni 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Yuni 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Yuni 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Misrotun 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Misrotun 19,500 500 20,000 - - - -
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Misrotun 1 19,500 500 20,000 20,000 19,500 9,945 9,945
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Misrotun 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
dr.Vera 17,500 32,500 50,000 - - - - - - -
Misrotun 17,500 32,500 50,000 - - - -
f. Suntik KB
dr.Agust 3,500 6,500 10,000 - - - - - - -
Misrotun 3,500 6,500 10,000 - - - -
dr.Vera 3,500 6,500 10,000 - - - - - - -
Misrotun 3,500 6,500 10,000 - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Santi 7 19,500 500 20,000 140,000 136,500 69,615 69,615
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
Santi 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Santi 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 3,500 6,500 10,000 - - - - - - -
Santi 3,500 6,500 10,000 - - - -
dr.Vera 3,500 6,500 10,000 - - - - - - -
Santi 3,500 6,500 10,000 - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Fajrin 1 19,500 500 20,000 20,000 19,500 9,945 9,945
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Fajrin 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Fajrin 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Fajrin 2 19,500 500 20,000 40,000 39,000 19,890 19,890
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 206 5,892,000 228,000 6,120,000 15,520,000 14,969,500 377,975 463,905 12,061,920 1,722,370 343,330 14,969,500
BAGIAN BULAN APRIL
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Dua Belas Juta Lima Ratus Dua Puluh Lima Ribu Delapan Ratus Dua Puluh Lima Rupiah
dengan rincian
Jaspel
Jasa Dinkes Langsung Tanda
No. Nama / Golongan Jabatan PPH Diterima
Pelayanan 1.5% s/d 5% Tangan
(60%s/d
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Persal dg tind
emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050 Rp. 11,408 Rp. 64,643
ANC Rp 468,000 Rp. 22,425 Rp. 42,120 Rp. 6,318 Rp. 35,802
PNC Rp 838,500 Rp. 41,925 Rp. 75,465 Rp. 11,320 Rp. 64,145
Pasang Implant Rp 35,000 Rp. 1,750 Rp. 3,150 Rp. 473 Rp. 2,678
2 dr.Tri Vera Handayani Dokter 2

Gol.III/b
Persal dg tind
emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050 3,803 Rp. 90,031
ANC Rp 780,000 Rp. 39,000 Rp. 70,200 3,510 Rp. 90,031

PNC Rp 1,287,000 Rp. 64,350 Rp. 115,830 5,792 Rp. 110,039
Pasang Implant Rp 35,000 Rp. 1,750 Rp. 3,150 158 Rp. 2,993
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 477,360 Rp. 477,360
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Elis Dianawati,A.md.ke Bidan 4
Gol.II/d
Persal dg tind Rp -
emergn.Dsr
ANC Rp. 29,835 Rp. 29,835
PNC Rp. 9,945 Rp. 9,945
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.II/c
Persal dg tind
emergn.Dsr
ANC Rp. 49,725 Rp. 49,725
PNC Rp. 59,670 Rp. 59,670
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.-
Persal dg tind Rp. 633,750 Rp. 15,844 Rp. 430,950 Rp. 430,950
emergn.Dsr
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 59,670 Rp. 59,670
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 19,890 Rp. 19,890
PNC Rp. 19,890 Rp. 19,890
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 159,120 Rp. 159,120
PNC Rp. 258,570 Rp. 258,570
Pasang IUD
Pasang Implant Rp. 35,700 Rp. 35,700
Suntik KB Rp. 10,710 Rp. 10,710
Pra Rujukan
9 Sri Pujiati,A.mD.Keb Bidan 9
Gol.II/b
ANC Rp. 39,780 Rp. 39,780
PNC Rp. 119,340 Rp. 119,340
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
10 Misrotun Bidan 10
Gol.III/c
Persal dg tind
emergn.Dsr
Pra Rujukan
ANC
PNC Rp. 39,780 2,013 Rp. 37,767
Pasang IUD
Pasang Implant
Suntik KB
11 Santi Bidan 11
Gol.-
emergn.Dsr
ANC Rp. 139,230 Rp. 139,230
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
12 Fajrin Bidan 12
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 39,780 Rp. 39,780
PNC Rp. 39,780 Rp. 39,780
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 Mei 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
dibayar
KPA Kegiatan Lunas dibayar tgl……………….
KPA Kegiatan Penyediaan Biaya Operasional Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Penyediaan Biaya
dan Pemeliharaan Kegiatan ( PPTK )
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
BAGIAN BULAN : APRIL
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Tujuh Ratus Dua Puluh Dua Ribu Tiga Ratus Tujuh Puluh Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 43,511
Rp 35,600
JUMLAH Rp. 1,722,370 Rp. 23,281 Rp. 1,699,089

NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya Lunas dibayar tgl……………….
Operasional dan Pemeliharaan Bendahara Pengeluaran Pembantu
Pejabat Pelaksana Teknik
Kegiatan ( PPTK )

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
RUDI EKO PRASETYO, S.Psi.
NIP. 19770304 200312 1 004
351750
tu
BAGIAN BULAN : APRIL
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Tiga Ratus Empat Puluh Tiga Ribu Tiga Ratus Tiga Puluh Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 62,805 5
Rp 62,805
JUMLAH Rp. 343,330 Rp. 22,819 Rp. 320,511


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN MEI 2013
BAHAN SPJ
Elis 487,500 12,500 500,000 - - - - - - -
Santi 487,500 12,500 500,000 - - - - - - -
Dwi 487,500 12,500 500,000 - - - - - - -
dr.Agust 2 633,750 16,250 650,000 1,300,000 1,267,500 31,688 152,100 190,125 31,688 405,600
Yuni 2 633,750 16,250 650,000 1,300,000 1,267,500 861,900 861,900
dr.Vera 3 633,750 16,250 650,000 1,950,000 1,901,250 47,531 228,150 285,188 47,531 608,400
Santi 3 633,750 16,250 650,000 1,950,000 1,901,250 1,292,850 1,292,850
dr.Agust 2 97,500 - 97,500 195,000 195,000 9,750 17,550 60,450 7,800 95,550
Rina 2 97,500 - 97,500 195,000 195,000 99,450 99,450
dr.Vera 1 97,500 - 97,500 97,500 97,500 4,875 8,775 30,225 3,900 47,775
Elis 1 97,500 - 97,500 97,500 97,500 49,725 49,725
f. Suntik KB
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Rina 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Yuni 3 19,500 500 20,000 60,000 58,500 29,835 29,835
Elis 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Dwi 19,500 500 20,000 - - - -
1 Polindes Ngasem
Suci 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Suci 3 19,500 500 20,000 60,000 58,500 29,835 29,835
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Suci 5 19,500 500 20,000 100,000 97,500 49,725 49,725
c. P N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Suci 8 19,500 500 20,000 160,000 156,000 79,560 79,560
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Suci 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
Suci 17,500 32,500 50,000 - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 1 17,500 32,500 50,000 50,000 17,500 875 1,575 5,425 700 8,575
Suci 1 17,500 32,500 50,000 50,000 17,500 8,925 8,925
dr.Vera 17,500 32,500 50,000 - - - - - - -
Suci 17,500 32,500 50,000 - - - -
f. Suntik KB
dr.Agust 4 3,500 6,500 10,000 40,000 14,000 700 1,260 4,340 560 6,860
Suci 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
dr.Vera 3,500 6,500 10,000 - - - - - - -
Suci 3,500 6,500 10,000 - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Sri Pujiati 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Sri Pujiati 19,500 500 20,000 - - - -
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
Sri Pujiati 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Sri Pujiati 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Rina Pangestu W. 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Rina Pangestu W. 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Rina Pangestu W. 19,500 500 20,000 - - - -
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Rina Pangestu W. 4 19,500 500 20,000 80,000 78,000 39,780 39,780
dr.Vera 19,500 500 20,000 - - - - - - -
Rina Pangestu W. 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Lisyati 10 19,500 500 20,000 200,000 195,000 99,450 99,450
dr.Vera 18 19,500 500 20,000 360,000 351,000 17,550 31,590 108,810 14,040 171,990
Lisyati 18 19,500 500 20,000 360,000 351,000 179,010 179,010
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
Lisyati 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Lisyati 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Yuni 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Yuni 19,500 500 20,000 - - - -
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Yuni 2 19,500 500 20,000 40,000 39,000 19,890 19,890
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Yuni 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Misrotun 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Misrotun 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Misrotun 10 19,500 500 20,000 200,000 195,000 99,450 99,450
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Misrotun 14 19,500 500 20,000 280,000 273,000 139,230 139,230
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
dr.Vera 17,500 32,500 50,000 - - - - - - -
Misrotun 17,500 32,500 50,000 - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Misrotun 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
dr.Vera 4 3,500 6,500 10,000 40,000 14,000 700 1,260 4,340 560 6,860
Misrotun 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Santi 6 19,500 500 20,000 120,000 117,000 59,670 59,670
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Santi 10 19,500 500 20,000 200,000 195,000 99,450 99,450
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 5 19,500 500 20,000 100,000 97,500 49,725 49,725
dr.Vera 11 19,500 500 20,000 220,000 214,500 10,725 19,305 66,495 8,580 105,105
Santi 11 19,500 500 20,000 220,000 214,500 109,395 109,395
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Santi 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Santi 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 487,500 12,500 500,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
Fajrin 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Fajrin 19,500 500 20,000 - - - -
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
Fajrin 19,500 500 20,000 - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Fajrin 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 184 3,857,000 158,000 4,015,000 14,152,500 13,687,250 349,206 668,790 10,736,685 1,615,423 317,146 13,687,250
BAGIAN BULAN MEI
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Sebelas Juta Empat Ratus Lima Ribu Empat Ratus Tujuh Puluh Lima Rupiah
dengan rincian
Jaspel Langsung
Jasa Dinkes Tanda
No. Nama / Golongan Jabatan PPH Diterima
Pelayanan 1.5% s/d 5% Tangan
(60%s/d 97,5%)
1 2 3 4 5 6 7 8 9
Gol.IV/a
Persal dg tind
emergn.Dsr Rp 1,267,500 Rp. 31,688 Rp. 152,100 Rp. 22,815 Rp. 129,285
ANC Rp 565,500 Rp. 28,275 Rp. 50,895 Rp. 7,634 Rp. 43,261
PNC Rp 565,500 Rp. 28,225 Rp. 50,895 Rp. 7,634 Rp. 43,261
Pasang Implant Rp 17,500 Rp. 875 Rp. 1,575 Rp. 236 Rp. 1,339
Suntik KB Rp 28,000 Rp. 1,400 Rp. 2,520 Rp. 378 Rp. 2,142
Gol.III/b
Persal dg tind
emergn.Dsr Rp 1,901,250 Rp. 47,531 Rp. 228,150 11,408 Rp. 90,031
ANC Rp 936,000 Rp. 46,800 Rp. 84,240 4,212 Rp. 90,031

PNC Rp 780,000 Rp. 29,000 Rp. 70,200 3,510 Rp. 66,690
Suntik KB Rp 21,000 Rp. 1,050 Rp. 1,890 101 Rp. 1,789
Pra Rujukan Rp. 97,500 Rp. 4,875 Rp. 8,775 439 Rp. 8,336
Pasang Implant
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 278,460 Rp. 278,460
PNC
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Elis Dianawati,A.md.keb Bidan 4
Gol.II/d
Persal dg tind
emergn.Dsr
ANC Rp. 39,780 Rp. 39,780
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan Rp. 49,725 Rp. 49,725
Transport Rujukan
Gol.II/c
Persal dg tind
emergn.Dsr
ANC Rp. 29,835 Rp. 29,835
PNC Rp. 39,780 Rp. 39,780
Pasang IUD
Pasang Implant
Suntik KB
Transport Rujukan
Gol.-
Persal dg tind Rp. 1,267,500 Rp. 31,688 Rp. 861,900 Rp. 861,900
emergn.Dsr
ANC Rp. 29,835 Rp. 29,835
PNC Rp. 49,725 Rp. 49,725
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 198,900 Rp. 198,900
Pasang IUD
Pra Rujukan
8 Misrotun Bidan 8
Gol.III/c
Pertolongan Persalinan Rp. 1,852,500 Rp. 1,852,500
Persal dg tind
emergn.Dsr
Pra Rujukan Rp -
ANC Rp. 129,285 Rp. 129,285
PNC Rp. 238,680 Rp. 238,680
Pasang IUD
Pasang Implant
Suntik KB Rp. 10,710 Rp. 10,710
9 Santi Bidan 9
Gol.-
Persal dg tind Rp. 1,901,250 Rp. 47,531 Rp. 1,292,850 Rp. 1,292,850
emergn.Dsr
ANC Rp. 179,010 Rp. 179,010
PNC Rp. 159,120 Rp. 159,120
Pasang IUD
Pasang Implant
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 Juni 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
dibayar
KPA
KPA Kegiatan
Kegiatan Penyediaan Biaya Operasional Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Penyediaan Biaya
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
Penyediaan Biaya
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
BAGIAN BULAN : MEI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Enam Ratus Lima Belas Ribu Empat Ratus Dua Puluh Tiga Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 40,810
Rp 33,390
JUMLAH Rp. 1,615,423 Rp. 21,833 Rp. 1,593,590

NIP.197308172002121003 NIP.198108262010012001
Kegiatan ( PPTK )
NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
.
ntu
BAGIAN BULAN : MEI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Tiga Ratus Tujuh Belas Ribu Seratus Empat Puluh Enam Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 58,015 5
Rp 58,015
JUMLAH Rp. 317,146 Rp. 21,079 Rp. 296,067


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN JUNI 2013
BAHAN SPJ
a. Persalinan Normal 487,500 12,500 500,000 - - - - - - -
Lisyati 2 487,500 12,500 500,000 1,000,000 975,000 24,375 780,000 146,250 24,375 975,000
Sri Pujiati 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Rina 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Yuni 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
dr.Vera 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
Rina 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
Dwi 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
dr.Agust 2 97,500 - 97,500 195,000 195,000 9,750 17,550 60,450 7,800 95,550
Fajrin 2 97,500 - 97,500 195,000 195,000 99,450 99,450
dr.Vera 1 97,500 - 97,500 97,500 97,500 4,875 8,775 30,225 3,900 47,775
Dwi 1 97,500 - 97,500 97,500 97,500 49,725 49,725
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Suci 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Dwi 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Fajrin 3 19,500 500 20,000 60,000 58,500 29,835 29,835
Santi 4 19,500 500 20,000 80,000 78,000 39,780 39,780
Elis 2 19,500 500 20,000 40,000 39,000 19,890 19,890
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Rina 3 19,500 500 20,000 60,000 58,500 29,835 29,835
Yuni 3 19,500 500 20,000 60,000 58,500 29,835 29,835
Suci 2 19,500 500 20,000 40,000 39,000 19,890 19,890
Dwi 3 19,500 500 20,000 60,000 58,500 29,835 29,835
1 Polindes Ngasem
Suci 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Suci 19 19,500 500 20,000 380,000 370,500 188,955 188,955
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Suci 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Suci 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Lisyati 24 19,500 500 20,000 480,000 468,000 238,680 238,680
c. P N C
dr.Agust 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
dr.Vera 13 19,500 500 20,000 260,000 253,500 12,675 22,815 78,585 10,140 124,215
Lisyati 28 19,500 500 20,000 560,000 546,000 278,460 278,460
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Misrotun 13 19,500 500 20,000 260,000 253,500 129,285 129,285
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Misrotun 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Misrotun 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 9 19,500 500 20,000 180,000 175,500 8,775 15,795 54,405 7,020 85,995
Santi 16 19,500 500 20,000 320,000 312,000 159,120 159,120
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Santi 3 3,500 6,500 10,000 30,000 10,500 5,355 5,355
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 8 487,500 12,500 500,000 4,000,000 3,900,000 58,500 3,705,000 78,000 58,500 3,900,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
Fajrin 20 19,500 500 20,000 400,000 390,000 198,900 198,900
c. P N C
dr.Agust 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Fajrin 21 19,500 500 20,000 420,000 409,500 208,845 208,845
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 3 3,500 6,500 10,000 30,000 10,500 525 945 3,255 420 5,145
Fajrin 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 231 6,234,500 180,500 6,415,000 18,472,500 17,943,000 446,213 512,145 14,577,780 2,000,655 406,208 17,943,000
BAGIAN BULAN JUNI
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Lima Belas Juta Delapan Puluh Sembilan Ribu Sembilan Ratus Dua Puluh Lima Rupiah
dengan rincian
Dinkes Jaspel Langsung

Jabata Jasa Tanda
No. Nama / Golongan 1.5% s/d PPH Diterima
n Pelayanan Tangan
5% (60%s/d 97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Persal dg tind
emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050 Rp. 11,408 Rp. 64,643
ANC Rp 643,500 Rp. 32,175 Rp. 57,915 Rp. 8,687 Rp. 49,228
PNC Rp 955,500 Rp. 47,775 Rp. 85,995 Rp. 12,899 Rp. 73,096
Pasang Implant
Suntik KB Rp 17,500 Rp. 875 Rp. 1,575 Rp. 236 Rp. 1,339
Gol.III/b
Persal dg tind
emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050 3,803 Rp. 90,031
ANC Rp 1,248,000 Rp. 62,400 Rp. 112,320 5,616 Rp. 90,031

PNC Rp 819,000 Rp. 40,950 Rp. 73,710 3,686 Rp. 70,025
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 238,680 Rp. 238,680
PNC Rp. 278,460 Rp. 278,460
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Sri Pujiati Bidan 4
Gol.II/c
Persal dg tind
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.II/c
emergn.Dsr
ANC
PNC Rp. 29,835 Rp. 29,835
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.-
ANC
PNC Rp. 29,835 Rp. 29,835
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
emergn.Dsr
ANC Rp. 19,890 Rp. 19,890
PNC Rp. 29,835 Rp. 29,835
Pasang IUD
Pasang Implant
Suntik KB
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 208,845 Rp. 208,845
PNC Rp. 49,725 Rp. 49,725
Pasang IUD
Pasang Implant
Pra Rujukan
9 Elis Dianawati Bidan 9
Gol.II/d
Persal dg tind
emergn.Dsr
ANC Rp. 19,890 Rp. 19,890
PNC
Pasang IUD
Pasang Implant
Suntik KB
Gol.III/c
Pertolongan Persalinan Rp. 975,000 Rp. 14,625 Rp. 926,250 Rp 46,313 Rp. 879,938
ANC Rp. 129,285 Rp 6,464 Rp. 122,821
PNC Rp. 119,340 Rp 5,967 Rp. 113,373
Pasang Implant
Suntik KB Rp. 7,140 Rp 365 Rp. 6,775
Pasang IUD
Pra Rujukan
Transport Rujukan
Transport Rujukan
11 Santi Bidan 11
Gol.-
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 159,120 Rp. 159,120
Pasang IUD
Pasang Implant
Pra Rujukan
Transport Rujukan
12 Fajrin Bidan 12
Gol.-
ANC Rp. 228,735 Rp. 228,735
PNC Rp. 208,845 Rp. 208,845
Pasang IUD
Pasang Implant
Transport Rujukan
Penanggungjawab Bojonegoro,03 Juli 2013


NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya
Operasional dan Pemeliharaan Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Kegiatan ( PPTK )
BAMBANG SURYANTO,
BAMBANG SH SH
SURYANTO, SRI WIDJIATI, SE.
NIP. 19660809 198803 1 010
NIP. 19770304 200312 1 004
BAGIAN BULAN : JUNI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Juta Enam Ratus Lima Puluh Lima Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 50,541
Rp 41,352
JUMLAH Rp. 2,000,655 Rp. 27,043 Rp. 1,973,612

NIP.197308172002121003 NIP.198108262010012001
Kegiatan ( PPTK )

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
….
antu
1
BAGIAN BULAN : JUNI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Empat Ratus Enam Ribu Dua Ratus Delapan Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
5 Hj.Sri Endang S.A.Md.Keb, II/c
Rp. 74,306 5
Rp 74,306
JUMLAH Rp. 406,208 Rp. 26,997 Rp. 379,211


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN JULI 2013
BAHAN SPJ
Dwi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Santi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Rina 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
dr.Vera 2 633,750 16,250 650,000 1,300,000 1,267,500 31,688 152,100 190,125 31,688 405,600
Rina 2 633,750 16,250 650,000 1,300,000 1,267,500 861,900 861,900
Fajrin 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
dr.Agust 1 97,500 - 97,500 97,500 97,500 4,875 8,775 30,225 3,900 47,775
Fajrin 1 97,500 - 97,500 97,500 97,500 49,725 49,725
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Elis 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C
1 Polindes Ngasem
Suci 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 18 19,500 500 20,000 360,000 351,000 17,550 31,590 108,810 14,040 171,990
Suci 28 19,500 500 20,000 560,000 546,000 278,460 278,460
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 17 19,500 500 20,000 340,000 331,500 16,575 29,835 102,765 13,260 162,435
Suci 24 19,500 500 20,000 480,000 468,000 238,680 238,680
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
dr.Vera 4 3,500 6,500 10,000 40,000 14,000 700 1,260 4,340 560 6,860
Suci 6 3,500 6,500 10,000 60,000 21,000 10,710 10,710
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 7 487,500 12,500 500,000 3,500,000 3,412,500 51,188 3,241,875 68,250 51,188 3,412,500
b. A N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Sri Pujiati 21 19,500 500 20,000 420,000 409,500 208,845 208,845
c. P N C
dr.Agust 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
dr.Vera 20 19,500 500 20,000 400,000 390,000 19,500 35,100 120,900 15,600 191,100
Sri Pujiati 35 19,500 500 20,000 700,000 682,500 348,075 348,075
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
dr.Vera 5 3,500 6,500 10,000 50,000 17,500 875 1,575 5,425 700 8,575
Sri Pujiati 7 3,500 6,500 10,000 70,000 24,500 12,495 12,495
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Rina 3 19,500 500 20,000 60,000 58,500 29,835 29,835
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
Lisyati 20 19,500 500 20,000 400,000 390,000 198,900 198,900
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Lisyati 21 19,500 500 20,000 420,000 409,500 208,845 208,845
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Misrotun 11 19,500 500 20,000 220,000 214,500 109,395 109,395
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
Misrotun 20 19,500 500 20,000 400,000 390,000 198,900 198,900
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
dr.Vera 3 3,500 6,500 10,000 30,000 10,500 525 945 3,255 420 5,145
Misrotun 5 3,500 6,500 10,000 50,000 17,500 8,925 8,925
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Santi 16 19,500 500 20,000 320,000 312,000 159,120 159,120
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 8 19,500 500 20,000 160,000 156,000 79,560 79,560
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Santi 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Fajrin 10 19,500 500 20,000 200,000 195,000 99,450 99,450
c. P N C
dr.Agust 11 19,500 500 20,000 220,000 214,500 10,725 19,305 66,495 8,580 105,105
dr.Vera 20 19,500 500 20,000 400,000 390,000 19,500 35,100 120,900 15,600 191,100
Fajrin 31 19,500 500 20,000 620,000 604,500 308,295 308,295
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 309 6,546,500 191,000 6,737,500 22,347,500 21,666,250 538,531 690,750 17,588,625 2,361,213 487,131 21,666,250
BAGIAN BULAN JULI
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Delapan Belas Juta Dua Ratus Tujuh Puluh Sembilan Ribu Tiga Ratus Tujuh Puluh Lima Rupiah
dengan rincian
Jaspel
Dinkes Langsung
Tanda
No. Nama / Golongan Jabatan Jasa Pelayanan 1.5% s/d PPH Diterima
Tangan
5% (60%s/d
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Persal dg tind emergn.Dsr
Rp 633,750 Rp. 15,844 Rp. 76,050 Rp. 11,408 Rp. 64,643
ANC Rp 819,000 Rp. 40,950 Rp. 73,710 Rp. 11,057 Rp. 62,654
PNC Rp 936,000 Rp. 46,800 Rp. 84,240 Rp. 12,636 Rp. 71,604
Pasang Implant
Gol.III/b
Rp 1,267,500 Rp. 31,688 Rp. 152,100 7,605 Rp. 90,031
ANC Rp 1,443,000 Rp. 71,550 Rp. 129,870 6,494 Rp. 90,031

PNC Rp 1,774,500 Rp. 88,725 Rp. 159,705 7,985 Rp. 151,720
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 198,900 Rp. 198,900
PNC Rp. 208,845 Rp. 208,845
Pra Rujukan
Pasang IUD
Pasang Implant
Suntik KB
Gol.II/c
Pertolongan Persalinan Rp 3,412,500 Rp. 51,188 Rp. 3,241,875 Rp. 3,241,875
ANC Rp. 208,845 Rp. 208,845

PNC Rp. 348,075 Rp. 348,075
Pasang IUD
Pasang Implant
Suntik KB Rp. 12,495 Rp. 12,495
Pra Rujukan
Transport Rujukan
Gol.II/c
Persal dg tind emergn.Dsr Rp. 1,267,500 Rp. 31,688 Rp. 861,900 Rp. 861,900
ANC Rp. 29,835 Rp. 29,835

PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.-
ANC Rp. 39,780 Rp. 39,780
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC Rp. 278,460 Rp. 278,460

PNC Rp. 238,680 Rp. 238,680
Pasang IUD
Pasang Implant
Suntik KB Rp. 10,710 Rp. 10,710
Pra Rujukan
Gol.II/d
ANC Rp. 29,835 Rp. 29,835

PNC
Pasang IUD
Pasang Implant
Suntik KB
Gol.III/c
Pertolongan Persalinan Rp. 1,462,500 Rp. 21,938 Rp. 1,389,375 Rp 69,469 Rp. 1,319,906
ANC Rp. 109,395 Rp 5,470 Rp. 103,925
PNC Rp. 198,900 Rp 9,945 Rp. 188,955
Pasang Implant
Suntik KB Rp. 8,925 Rp 456 Rp. 8,469
Pasang IUD
Pra Rujukan
Transport Rujukan
Transport Rujukan
11 Santi Bidan 11
Gol.-
ANC Rp. 159,120 Rp. 159,120
PNC Rp. 79,560 Rp. 79,560
Pasang IUD
Pasang Implant
Pra Rujukan
Transport Rujukan
12 Fajrin Bidan 12
Gol.-
Persal dg tind emergn.Dsr Rp. 633,750 Rp. 31,688 Rp. 430,950 Rp. 430,950
ANC Rp. 99,450 Rp. 99,450

PNC Rp. 308,295 Rp. 308,295
Pasang IUD
Pasang Implant
Suntik KB
Transport Rujukan
Penanggungjawab Bojonegoro,03 Agustus 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju dibayar dibayar

Mengetahui/setuju
KPA Kegiatan Penyediaan Biaya Biaya
KPA Kegiatan Penyediaan Lunas dibayar tgl……………….
Kegiatan ( PPTK )
BAMBANG SURYANTO,
BAMBANG SH
SURYANTO, SH SRI WIDJIATI, SE.
NIP. 19660809 198803 1198803
NIP. 19770304 200312 1 004
piah
315
BAGIAN BULAN : JULI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Juta Tiga Ratus Enam Puluh Satu Ribu Dua Ratus Tiga Belas Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 59,650
Rp 48,805
JUMLAH Rp. 2,361,213 Rp. 31,917 Rp. 2,329,296

NIP.197308172002121003 NIP.198108262010012001
Kegiatan ( PPTK )

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
BAGIAN BULAN : JULI
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Empat Ratus Delapan Puluh Tujuh Ribu Seratus Tiga Puluh Satu Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 89,110 5
Rp 89,110
JUMLAH Rp. 487,131 Rp. 32,376 Rp. 454,755


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN AGUSTUS 2013
BAHAN SPJ
Santi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Rina 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
dr.Vera 3 633,750 16,250 650,000 1,950,000 1,901,250 47,531 228,150 285,188 47,531 608,400
Rina 2 633,750 16,250 650,000 1,300,000 1,267,500 861,900 861,900
Dwi 2 633,750 16,250 650,000 1,300,000 1,267,500 861,900 861,900
dr.Agust 2 97,500 - 97,500 195,000 195,000 9,750 17,550 60,450 7,800 95,550
Rina 2 97,500 - 97,500 195,000 195,000 99,450 99,450
dr.Vera 1 97,500 - 97,500 97,500 97,500 4,875 8,775 30,225 3,900 47,775
Elis 1 97,500 - 97,500 97,500 97,500 49,725 49,725
b. A N C
c. P N C
1 Polindes Ngasem
Suci 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Suci 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Suci 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 3 3,500 6,500 10,000 30,000 10,500 525 945 3,255 420 5,145
Suci 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Sri Pujiati 2 19,500 500 20,000 40,000 39,000 19,890 19,890
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Sri Pujiati 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Rina 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Rina 1 19,500 500 20,000 20,000 19,500 9,945 9,945
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Elis 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Lisyati 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Lisyati 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Vera 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Yuni 1 19,500 500 20,000 20,000 19,500 9,945 9,945
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Santi 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 9 19,500 500 20,000 180,000 175,500 8,775 15,795 54,405 7,020 85,995
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Santi 19 19,500 500 20,000 380,000 370,500 188,955 188,955
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Fajrin 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Fajrin 1 19,500 500 20,000 20,000 19,500 9,945 9,945
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 132 5,658,500 146,500 5,805,000 12,072,500 11,753,000 295,150 519,570 9,281,730 1,385,330 271,220 11,753,000
BAGIAN BULAN AGUSTUS
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Sembilan Juta Delapan Ratus Satu Ribu Tiga Ratus Rupiah
dengan rincian
Jaspel
Dinkes Langsung
Tanda
Tangan
5% (60%s/d
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Rp 633,750 Rp. 15,844 Rp. 76,050 Rp. 11,408 Rp. 64,643
ANC Rp 487,500 Rp. 24,375 Rp. 43,875 Rp. 6,581 Rp. 37,294
PNC Rp 487,500 Rp. 24,375 Rp. 43,875 Rp. 6,581 Rp. 37,294
Pasang Implant
Gol.III/b
Persal dg tind emergn.Dsr Rp. 216,742
Rp 1,901,250 Rp. 47,531 Rp. 228,150 11,408
ANC Rp 643,500 Rp. 32,175 Rp. 57,915 2,896 Rp. 55,019

PNC Rp 468,000 Rp. 23,400 Rp. 42,120 2,106 Rp. 40,014
Suntik KB Rp 10,500 Rp. 525 Rp. 945 52 Rp. 893
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 119,340 Rp. 119,340
Pra Rujukan
Pasang IUD
Pasang Implant
Suntik KB
Gol.II/c
ANC Rp. 19,890 Rp. 19,890

PNC Rp. 29,835 Rp. 29,835
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.II/c
ANC Rp. 39,780 Rp. 39,780

PNC Rp. 9,945 Rp. 9,945
Pasang IUD
Pasang Implant
Suntik KB
Transport Rujukan
Gol.-
ANC Rp. 39,780 Rp. 39,780
PNC Rp. 9,945 Rp. 9,945
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC Rp. 119,340 Rp. 119,340

PNC Rp. 119,340 Rp. 119,340
Pasang IUD
Pasang Implant
Pra Rujukan
Gol.II/d
Pra Rujukan Rp. 97,500 Rp. 4,875 Rp. 49,725 Rp. 49,725
ANC Rp. 39,780 Rp. 39,780
PNC
Pasang IUD
Pasang Implant
Suntik KB
10 Santi Bidan 10
Gol.-
Pertolongan Persalinan Rp. 487,500 Rp. 12,188 Rp. 1,316,250 Rp. 1,316,250
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 188,955 Rp. 188,955
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
11 Fajrin Bidan 11
Gol.-
ANC Rp. 79,560 Rp. 79,560

PNC Rp. 9,945 Rp. 9,945
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 September 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju dibayardibayar
Mengetahui/setuju
KPA Kegiatan Penyediaan
KPA Kegiatan Biaya Biaya
Penyediaan Lunas dibayar tgl……………….
Kegiatan ( PPTK )
BAMBANG SURYANTO,
BAMBANG SH SH
SURYANTO, SRI WIDJIATI, SE.
NIP. 19660809 198803 1 010
NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
BAGIAN BULAN : AGUSTUS
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Tiga Ratus Delapan Puluh Lima Ribu Tiga Ratus Tiga Puluh Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 34,997
Rp 28,634
JUMLAH Rp. 1,385,330 Rp. 18,724 Rp. 1,366,606

NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya Pejabat Pelaksana Teknik
Operasional dan Pemeliharaan )Kegiatan (PPTK' Bendahara Pengeluaran Pembantu
BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI, SE.

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
….
ntu
BAGIAN BULAN : AGUSTUS
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Ratus Tujuh Puluh Satu Ribu Dua Ratus Dua Puluh Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 49,614 5
Rp 49,614
JUMLAH Rp. 271,220 Rp. 18,027 Rp. 253,193


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN SEPTEMBER 2013
BAHAN SPJ
Dwi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Fajrin 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
b. Persal Dgn Tind. Emerg. Dsr 1
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
Yuni 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
b. A N C
c. P N C
1 Polindes Ngasem
Suci 7 487,500 12,500 500,000 3,500,000 3,412,500 51,188 3,241,875 68,250 51,188 3,412,500
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 15 19,500 500 20,000 300,000 292,500 14,625 26,325 90,675 11,700 143,325
Suci 25 19,500 500 20,000 500,000 487,500 248,625 248,625
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Suci 7 19,500 500 20,000 140,000 136,500 69,615 69,615
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Suci 3 3,500 6,500 10,000 30,000 10,500 5,355 5,355
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Rina 3 19,500 500 20,000 60,000 58,500 29,835 29,835
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Lisyati 15 19,500 500 20,000 300,000 292,500 149,175 149,175
c. P N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Lisyati 22 19,500 500 20,000 440,000 429,000 218,790 218,790
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Yuni 7 19,500 500 20,000 140,000 136,500 69,615 69,615
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Santi 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Santi 11 19,500 500 20,000 220,000 214,500 109,395 109,395
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 6 487,500 12,500 500,000 3,000,000 2,925,000 43,875 2,778,750 58,500 43,875 2,925,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Fajrin 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 16 19,500 500 20,000 320,000 312,000 15,600 28,080 96,720 12,480 152,880
Fajrin 26 19,500 500 20,000 520,000 507,000 258,570 258,570
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 159 3,757,250 102,750 3,860,000 12,900,000 12,558,750 297,656 315,675 10,441,950 1,232,438 271,031 12,558,750
BAGIAN BULAN SEPTEMBER
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Sepuluh Juta Tujuh Ratus Lima Puluh Tujuh Ribu Enam Ratus Dua puluh Lima Rupiah
dengan rincian
Jaspel
Dinkes Langsung
Tanda
Tangan
5% (60%s/d
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Persal dg tind emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050 Rp. 11,408 Rp. 64,643
ANC Rp 468,000 Rp. 23,400 Rp. 42,120 Rp. 6,318 Rp. 35,802
PNC Rp 643,500 Rp. 32,175 Rp. 57,915 Rp. 8,687 Rp. 49,228
Pasang Implant
Gol.III/b
ANC Rp 702,000 Rp. 35,100 Rp. 63,180 3,159 Rp. 60,021
PNC Rp 838,500 Rp. 41,925 Rp. 75,465 3,773 Rp. 71,692
3 Lisyati Bidan 3
Gol.II/c
Persalinan Normal Rp. 975,000 Rp. 14,625 Rp. 926,250 Rp. 926,250
ANC Rp. 149,175 Rp. 149,175
PNC Rp. 218,790 Rp. 218,790
Pra Rujukan
Pasang IUD
Pasang Implant
Suntik KB
Gol.II/c
ANC
PNC Rp. 29,835 Rp. 29,835
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Gol.-
Persal dg tind emergn.Dsr Rp. 633,750 Rp. 15,844 Rp. 430,950 Rp. 430,950
ANC
PNC Rp. 69,615 Rp. 69,615
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
ANC Rp. 248,625 Rp. 248,625
PNC Rp. 69,615 Rp. 69,615
Pasang IUD
Pasang Implant
Pra Rujukan
10 Santi Bidan 10
Gol.-
Pertolongan Persalinan Rp. 926,250 Rp. 926,250
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 109,395 Rp. 109,395
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
11 Fajrin Bidan 11
Gol.-
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 258,570 Rp. 258,570
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 Oktober 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju dibayar dibayar
Mengetahui/setuju
KPA Kegiatan Penyediaan Biaya Biaya
KPA Kegiatan Penyediaan Lunas dibayar tgl……………….
Kegiatan ( PPTK )
BAMBANG SURYANTO,
BAMBANG SH
NIP. 19660809 198803 1 010
NIP. 19770304 200312 1 004
BAMBANG SURYANTO,
BAMBANG SH
NIP. 19660809 198803 1 010
NIP. 19770304 200312 1 004
BAGIAN BULAN : SEPTEMBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Dua Ratus Tiga Puluh Dua Ribu Empat Ratus Tiga Puluh Delapan Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 31,134
Rp 25,474
JUMLAH Rp. 1,232,438 Rp. 16,658 Rp. 1,215,780

NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
piah
351750
BAGIAN BULAN : SEPTEMBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Ratus Tujuh Puluh Satu Ribu Tiga Puluh Satu Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 49,579 5
Rp 49,579
JUMLAH Rp. 271,031 Rp. 18,014 Rp. 253,017


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN OKTOBER 2013
BAHAN SPJ
Dwi 2 487,500 12,500 500,000 1,000,000 975,000 24,375 780,000 146,250 24,375 975,000
Yuni 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Rina 1 97,500 - 97,500 97,500 97,500 4,875 58,500 30,225 3,900 97,500
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Fajrin 3 3,500 6,500 10,000 30,000 10,500 5,355 5,355
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Suci 6 19,500 500 20,000 120,000 117,000 59,670 59,670
c. P N C
1 Polindes Ngasem
Suci 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Suci 6 19,500 500 20,000 120,000 117,000 59,670 59,670
c. P N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 11 19,500 500 20,000 220,000 214,500 10,725 19,305 66,495 8,580 105,105
Suci 18 19,500 500 20,000 360,000 351,000 179,010 179,010
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
dr.Agust 1 17,500 32,500 50,000 50,000 17,500 875 1,575 5,425 700 8,575
Suci 1 17,500 32,500 50,000 50,000 17,500 8,925 8,925
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Suci 1 3,500 6,500 10,000 10,000 3,500 1,785 1,785
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Lisyati 9 19,500 500 20,000 180,000 175,500 89,505 89,505
c. P N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Lisyati 10 19,500 500 20,000 200,000 195,000 99,450 99,450
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
dr.Agust 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
dr.Vera 2 19,500 500 20,000 40,000 39,000 1,950 3,510 12,090 1,560 19,110
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Misrotun 7 19,500 500 20,000 140,000 136,500 69,615 69,615
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Misrotun 15 19,500 500 20,000 300,000 292,500 149,175 149,175
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 1 17,500 32,500 50,000 50,000 17,500 875 1,575 5,425 700 8,575
dr.Vera 1 17,500 32,500 50,000 50,000 17,500 875 1,575 5,425 700 8,575
Misrotun 2 17,500 32,500 50,000 100,000 35,000 17,850 17,850
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Misrotun 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Santi 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Santi 8 19,500 500 20,000 160,000 156,000 79,560 79,560
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
Fajrin 1 19,500 500 20,000 20,000 19,500 9,945 9,945
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 112 3,282,500 165,000 3,447,500 7,147,500 6,840,000 186,000 168,075 5,422,800 896,775 166,350 6,840,000
BAGIAN BULAN OKTOBER
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Lima Juta Lima Ratus Sembilan Puluh Ribu Delapan Ratus Tujuh Puluh Lima Rupiah
dengan rincian
Jaspel
Dinkes Langsung
Tanda
Tangan
5% (60%s/d
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
Persal dg tind
emergn.Dsr
ANC Rp 273,000 Rp. 13,650 Rp. 24,570 Rp. 3,686 Rp. 20,885
PNC Rp 448,500 Rp. 22,425 Rp. 40,365 Rp. 6,055 Rp. 34,310
Pasang Implant Rp 17,500 Rp. 875 Rp. 1,575 Rp. 236 Rp. 1,339
Pasang IUD Rp 17,500 Rp. 875 Rp. 1,575 Rp. 236 Rp. 1,339
Gol.III/b
ANC Rp 429,000 Rp. 21,450 Rp. 38,610 1,931 Rp. 36,680
PNC Rp 643,500 Rp. 32,175 Rp. 57,915 2,896 Rp. 55,019
Pasang Implant Rp 17,500 Rp. 875 Rp. 1,575 97 Rp. 1,478
3 Lisyati Bidan 3
Gol.II/c
Persalinan Normal Rp. 487,500 Rp. 7,313 Rp. 463,125 Rp. 463,125
ANC Rp. 89,505 Rp. 89,505
PNC Rp. 99,450 Rp. 99,450
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
Gol.II/c
Persal dg tind
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Transport Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC
PNC Rp. 39,780 Rp. 39,780
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 179,010 Rp. 179,010
Pasang IUD
Pra Rujukan
8 Misrotun Bidan 8
Gol.III/c
Persal dg tind
emergn.Dsr
Pra Rujukan
ANC Rp. 69,615 Rp. 69,615
PNC Rp. 149,175 Rp. 149,175
Pasang IUD
9 Santi Bidan 9
Gol.-
ANC Rp. 79,560 Rp. 79,560
PNC Rp. 79,560 Rp. 79,560
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
10 Fajrin Bidan 10
Gol.-
Persal dg tind
emergn.Dsr
ANC
PNC Rp. 9,945 Rp. 9,945
Pasang IUD Rp. 5,355 Rp. 5,355
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 Nopember 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
dibayar
KPAKPA
Kegiatan Penyediaan Biaya Operasional Pejabat Pelaksana Teknik
Kegiatan
Bendahara Pengeluaran Pembantu
Kegiatan ( PPTK )
Penyediaan dan Pemeliharaan
Biaya
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
KPA Kegiatan Kegiatan ( PPTK )
Penyediaan dan Pemeliharaan
Biaya
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
BAGIAN BULAN : OKTOBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Delapan Ratus Sembilan Puluh Enam Ribu Tujuh Ratus Tujuh Puluh Lima Rupiah
dengan rincian :
1 2 3 5 7 8 9
7 Bobby Analis Rp. 927 Rp. 17,609 7
14
Rp 22,655
Rp 18,536
JUMLAH Rp. 896,775 Rp. 12,121 Rp. 884,654

NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19631201 200112 2 001
NIP. 19770304 200312 1 004
351750
…….
bantu
01
BAGIAN BULAN : OKTOBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Seratus Enam Puluh Enam Ribu Tiga Ratus Lima Puluh Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 30,429 5
Rp 30,429
JUMLAH Rp. 166,350 Rp. 11,056 Rp. 155,294


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN NOPEMBER 2013
BAHAN SPJ
Dwi 487,500 12,500 500,000 - - - - - - -
Yuni 487,500 12,500 500,000 - - - - - - -
dr.Agust 1 633,750 16,250 650,000 650,000 633,750 15,844 76,050 95,063 15,844 202,800
Yuni 1 633,750 16,250 650,000 650,000 633,750 430,950 430,950
dr.Agust 1 97,500 - 97,500 97,500 97,500 4,875 8,775 30,225 3,900 47,775
Rina 1 97,500 - 97,500 97,500 97,500 49,725 49,725
f. Suntik KB
dr.Agust 3,500 6,500 10,000 - - - - - - -
dr.Vera 3,500 6,500 10,000 - - - - - - -
Fajrin 3,500 6,500 10,000 - - - -
b. A N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Suci 8 19,500 500 20,000 160,000 156,000 79,560 79,560
c. P N C
1 Polindes Ngasem
Suci 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 18 19,500 500 20,000 360,000 351,000 17,550 31,590 108,810 14,040 171,990
Suci 28 19,500 500 20,000 560,000 546,000 278,460 278,460
c. P N C
dr.Agust 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Suci 26 19,500 500 20,000 520,000 507,000 258,570 258,570
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
Suci 17,500 32,500 50,000 - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 7 3,500 6,500 10,000 70,000 24,500 1,225 2,205 7,595 980 12,005
Suci 7 3,500 6,500 10,000 70,000 24,500 12,495 12,495
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
dr.Vera 9 19,500 500 20,000 180,000 175,500 8,775 15,795 54,405 7,020 85,995
Lisyati 16 19,500 500 20,000 320,000 312,000 159,120 159,120
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
Lisyati 8 19,500 500 20,000 160,000 156,000 79,560 79,560
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Yuni 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Yuni 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
dr.Vera 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
Misrotun 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 4 19,500 500 20,000 80,000 78,000 3,900 7,020 24,180 3,120 38,220
Misrotun 7 19,500 500 20,000 140,000 136,500 69,615 69,615
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
dr.Agust 17,500 32,500 50,000 - - - - - - -
dr.Vera 17,500 32,500 50,000 - - - - - - -
Misrotun 17,500 32,500 50,000 - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Misrotun 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 1 487,500 12,500 500,000 500,000 487,500 7,313 463,125 9,750 7,313 487,500
b. A N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Santi 4 19,500 500 20,000 80,000 78,000 39,780 39,780
c. P N C
dr.Agust 19,500 500 20,000 - - - - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Santi 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 2 487,500 12,500 500,000 1,000,000 975,000 14,625 926,250 19,500 14,625 975,000
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Fajrin 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Fajrin 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 160 3,877,750 109,750 3,987,500 9,577,500 9,284,250 243,619 328,095 7,416,705 1,080,218 215,614 9,284,250
BAGIAN BULAN NOPEMBER
PUSKESMAS NGASEM
TAHUN ANGGARAN 2013
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Tujuh Juta Tujuh Ratus Empat Puluh Empat Ribu Delapan Ratus Rupiah
dengan rincian
Jaspel
Dinkes Langsung
1.5% s/d 5%
(60%s/d
97,5%)
1 2 3 4 5 6 7 8
1 dr.Agust Fariono Kapus

Gol.IV/a
Persal dg tind Rp. 11,408 Rp. 64,643
emergn.Dsr Rp 633,750 Rp. 15,844 Rp. 76,050
ANC Rp 604,500 Rp. 30,225 Rp. 54,405 Rp. 8,161 Rp. 46,244
PNC Rp 448,500 Rp. 22,425 Rp. 40,365 Rp. 6,055 Rp. 34,310
Pra Rujukan Rp 97,500 Rp. 4,875 Rp. 8,775 Rp. 1,316 Rp. 7,459
Pasang IUD
2 dr.Tri Vera Handayani Dokter
Gol.III/b
ANC Rp 1,033,500 Rp. 51,675 Rp. 93,015 4,651 Rp. 88,364
PNC Rp 585,000 Rp. 29,250 Rp. 52,650 2,633 Rp. 50,018
Pasang Implant
3 Lisyati Bidan
Gol.II/c
ANC Rp. 159,120 Rp. 159,120
PNC Rp. 79,560 Rp. 79,560
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Rina Pangestu Bidan
Gol.-
Persal dg tind
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
5 Yuni Susetyawati Bidan
Gol.-
emergn.Dsr
ANC Rp. 39,780 Rp. 39,780
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
6 Suci Mukti Bidan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 358,020 Rp. 358,020
PNC Rp. 258,570 Rp. 258,570
Pasang IUD
Pasang Implant
Suntik KB Rp. 12,495 Rp. 12,495
Pra Rujukan
7 Misrotun Bidan
Gol.III/c
Pertolongan Persalinan Rp. 975,000 Rp. 14,625 Rp. 926,250 46,313 Rp. 879,938
Persal dg tind
emergn.Dsr
Pra Rujukan
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 69,615 Rp. 69,615
Pasang IUD
Pasang Implant
8 Santi Bidan
Gol.-
ANC Rp. 39,780 Rp. 39,780
PNC
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
9 Fajrin Bidan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 119,340 Rp. 119,340
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
Penanggungjawab Bojonegoro,03 Desember 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
dibayar Lunas dibayar tgl……………….
KPAKPA
Kegiatan Penyediaan Biaya Operasional dan Pejabat Pelaksana Teknik
Kegiatan Bendahara Pengeluaran Pembantu
Kegiatan ( PPTK )
Penyediaan BiayaPemeliharaan
Operasional dan
Pemeliharaan
NIP. 19770304 200312 1 004
BAMBANG
SURYANTO, SH
NIP. 19660809
198803 1 010
NIP. 19660809
198803 1 010
Tanda
Tangan
5
6
….
bantu
01
BAGIAN BULAN : NOVEMBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Delapan Puluh Ribu Dua Ratus Delapan Belas Rupiah
dengan rincian :
1 2 3 5 7 8 9
7 Bobby Analis Rp 22,327 Rp. 1,116 Rp. 21,211 7
Marcandra,A.Md.AK,III/a
14 Hj.Sri Endang S.A.Md.Keb,II/c Bikor Rp 27,289 Rp. 27,289
14
15 Rina Pangestu W.A.Md.Keb,II/b Bidan Rp 22,327 Rp. 22,327 15

JUMLAH Rp. 1,080,218 Rp. 14,602 Rp. 1,065,616

NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya Operasional dan Lunas dibayar tgl……………….
Pemeliharaan Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
Kegiatan ( PPTK )

NIP. 19770304 200312 1 004
351750
…….
mbantu
001
BAGIAN BULAN : NOPEMBER
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Ratus Lima Belas Ribu Enam Ratus Empat Belas Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
1 dr.H.M.Agust Fariono ,IV/a Kapus Rp. 55,218 Rp. 8,283 Rp. 46,935 1
2 dr.Tri Vera Handayani,III/b Dokter Rp. 47,330 Rp. 2,367 Rp. 44,963 2
3 Isnaniatin,III/b TU Rp. 39,442 Rp. 1,972 Rp. 37,470 3
4 Utuh Sujadi,s.Kep ,III/b Perkor Rp. 34,183 Rp. 1,709 Rp. 32,474 4
5 Hj.Sri Endang S.A.Md.Keb, II/c Bikor Rp. 39,441
Rp. 39,441 5
JUMLAH Rp. 215,614 Rp. 14,331 Rp. 201,283


NIP.197308172002121003 NIP.198108262010012001

NIP. 19660809 198803 1 010 NIP. 19770304 200312 1 004 NIP.196312012001122001
60 1 1
8 8
5 5
2 2
4 4
PUSKESMAS NGASEM BULAN DESEMBER 2013
BAHAN SPJ
Santi 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
Rina 1 487,500 12,500 500,000 500,000 487,500 12,188 390,000 73,125 12,188 487,500
dr.Agust 3 633,750 16,250 650,000 1,950,000 1,901,250 47,531 228,150 285,188 47,531 608,400
dr.Vera 5 633,750 16,250 650,000 3,250,000 3,168,750 79,219 380,250 475,313 79,219 1,014,000
Rina 4 633,750 16,250 650,000 2,600,000 2,535,000 1,723,800 1,723,800
Fajrin 4 633,750 16,250 650,000 2,600,000 2,535,000 1,723,800 1,723,800
dr.Agust 2 97,500 - 100,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Rina 2 97,500 - 100,000 200,000 195,000 99,450 99,450
dr.Vera 2 97,500 - 100,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Suci 2 97,500 - 100,000 200,000 195,000 99,450 99,450
b. A N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Santi 20 19,500 500 20,000 400,000 390,000 198,900 198,900
c. P N C
dr.Agust 1 19,500 500 20,000 20,000 19,500 975 1,755 6,045 780 9,555
dr.Vera 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
Lisyati 4 19,500 500 20,000 80,000 78,000 39,780 39,780
1 Polindes Ngasem
Suci 4 487,500 12,500 500,000 2,000,000 1,950,000 29,250 1,852,500 39,000 29,250 1,950,000
b. A N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 14 19,500 500 20,000 280,000 273,000 13,650 24,570 84,630 10,920 133,770
Suci 24 19,500 500 20,000 480,000 468,000 238,680 238,680
c. P N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Suci 20 19,500 500 20,000 400,000 390,000 198,900 198,900
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
e. Pasang IUD 1 17,500 32,500 50,000 50,000 17,500 875 10,500 5,425 700 17,500
f. Suntik KB
dr.Agust 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Suci 4 3,500 6,500 10,000 40,000 14,000 7,140 7,140
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Sri Pujiati 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Sri Pujiati 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
Sri Pujiati 11 19,500 500 20,000 220,000 214,500 109,395 109,395
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
Sri Pujiati 2 3,500 6,500 10,000 20,000 7,000 3,570 3,570
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Rina 19,500 500 20,000 - - - -
c. P N C 19,500 500 20,000 - - - - - - -
dr.Agust 19,500 500 20,000 - - - - - - -
Rina 19,500 500 20,000 - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
- - - - - - - - - -
b. A N C
dr.Agust 19,500 500 20,000 - - - - - - -
dr.Vera 19,500 500 20,000 - - - - - - -
Elis 19,500 500 20,000 - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
b. A N C 19,500 500 20,000 - - - - - - -
c. P N C 19,500 500 20,000 - - - - - - -
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
6 Polindes Kolong
Lisyati 5 487,500 12,500 500,000 2,500,000 2,437,500 36,563 2,315,625 48,750 36,563 2,437,500
b. A N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Lisyati 20 19,500 500 20,000 400,000 390,000 198,900 198,900
c. P N C
dr.Agust 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
dr.Vera 12 19,500 500 20,000 240,000 234,000 11,700 21,060 72,540 9,360 114,660
Lisyati 22 19,500 500 20,000 440,000 429,000 218,790 218,790
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
7 Polindes Butoh
Yuni 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Yuni 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 3 19,500 500 20,000 60,000 58,500 2,925 5,265 18,135 2,340 28,665
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Yuni 10 19,500 500 20,000 200,000 195,000 99,450 99,450
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB 3,500 6,500 10,000 - - - - - - -
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
8 Polindes Setren
Misrotun 487,500 12,500 500,000 - - - - - - -
b. A N C
c. P N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Misrotun 12 19,500 500 20,000 240,000 234,000 119,340 119,340
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
dr.Agust 1 3,500 6,500 10,000 10,000 3,500 175 315 1,085 140 1,715
dr.Vera 2 3,500 6,500 10,000 20,000 7,000 350 630 2,170 280 3,430
Misrotun 3 3,500 6,500 10,000 30,000 10,500 5,355 5,355
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Santi 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 6 19,500 500 20,000 120,000 117,000 5,850 10,530 36,270 4,680 57,330
dr.Vera 10 19,500 500 20,000 200,000 195,000 9,750 17,550 60,450 7,800 95,550
Santi 16 19,500 500 20,000 320,000 312,000 159,120 159,120
c. P N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 9 19,500 500 20,000 180,000 175,500 8,775 15,795 54,405 7,020 85,995
Santi 17 19,500 500 20,000 340,000 331,500 169,065 169,065
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Fajrin 3 487,500 12,500 500,000 1,500,000 1,462,500 21,938 1,389,375 29,250 21,938 1,462,500
b. A N C
dr.Agust 5 19,500 500 20,000 100,000 97,500 4,875 8,775 30,225 3,900 47,775
dr.Vera 7 19,500 500 20,000 140,000 136,500 6,825 12,285 42,315 5,460 66,885
Fajrin 12 19,500 500 20,000 240,000 234,000 119,340 119,340
c. P N C
dr.Agust 8 19,500 500 20,000 160,000 156,000 7,800 14,040 48,360 6,240 76,440
dr.Vera 11 19,500 500 20,000 220,000 214,500 10,725 19,305 66,495 8,580 105,105
Fajrin 19 19,500 500 20,000 380,000 370,500 188,955 188,955
d. Pasang IUD 17,500 32,500 50,000 - - - - - - -
e. Pasang Implant 17,500 32,500 50,000 - - - - - - -
f. Suntik KB
g. Pra Rujukan 100,000 - 100,000 - - - - - - -
Jumlah 276 5,683,000 192,000 5,880,000 21,860,000 21,226,000 551,863 1,051,740 16,475,985 2,643,985 502,428 21,226,000
Penanggungjawab Bojonegoro, 30 Desember 2013

Kepala UPTD Puskesmas Ngasem Verifikator Kabupaten Bendahara Puskesmas
dr.H.M.AGUST FARIONO ABDUL ROCHMAN,S.Kep dr.TRI VERA HANDAYANI

NIP.197308172002121003 NIP.198003062005011008 NIP.198108262010012001
BAGIAN BULAN DESEMBER
PUSKESMAS NGASEM
BEBAN ANGGARAN PAPBD KABUPATEN BOJONEGORO
TAHUN ANGGARAN 2015
KODE REKENING 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG Tujuh Belas Juta Lima Ratus Dua Puluh Tujuh Ribu Tujuh Ratus Dua Puluh Lima Rupiah
dengan rincian
Jaspel
Dinkes Langsung Tanda
1.5% s/d 5% (60%s/d Tangan
97,5%)
1 2 3 4 5 6 7 8 9

Gol.IV/a
emergn.Dsr Rp 1,901,250 Rp. 47,531 Rp. 228,150
ANC Rp 1,014,000 Rp. 38,025 Rp. 82,485 Rp. 12,373 Rp. 70,112
PNC Rp 936,000 Rp. 46,800 Rp. 84,240 Rp. 12,636 Rp. 71,604
Pra Rujukan Rp 195,000 Rp. 9,750 Rp. 17,550 Rp. 2,633 Rp. 14,918
Suntik KB Rp 14,000 Rp. 700 Rp. 1,260 Rp. 189 Rp. 1,071
Pasang IUD
Gol.III/b
Persal dg tind Rp 19,013 Rp. 361,238
emergn.Dsr Rp 3,168,750 Rp. 79,219 Rp. 380,250
Pra Rujukan Rp 195,000 Rp. 9,750 Rp. 17,550 Rp 878 Rp. 16,673
ANC Rp 1,345,500 Rp. 67,275 Rp. 121,095 6,055 Rp. 115,040
PNC Rp 1,306,500 Rp. 65,325 Rp. 117,585 5,879 Rp. 111,706
Pasang Implant
Gol.II/c
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 109,395 Rp. 109,395
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
3 Lisyati Bidan 3
Gol.II/c
ANC Rp. 198,900 Rp. 198,900
PNC Rp. 258,570 Rp. 258,570
Pra Rujukan
Persal dg tind
emergn.Dsr
Pasang IUD
Pasang Implant
Suntik KB
4 Rina Pangestu Bidan 4
Gol.-
emergn.Dsr
ANC
PNC
Pasang IUD
Pasang Implant
Suntik KB
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 99,450 Rp. 99,450
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Gol.-
Persal dg tind
emergn.Dsr
ANC Rp. 238,680 Rp. 238,680
PNC Rp. 198,900 Rp. 198,900
Pasang IUD Rp. 10,500 Rp. 10,500
Pasang Implant
7 Misrotun Bidan 7
Gol.III/c
Persal dg tind
emergn.Dsr
Pra Rujukan
ANC
PNC Rp. 119,340 Rp 5,967 Rp. 113,373
Pasang IUD
Pasang Implant
Suntik KB Rp. 5,355 Rp 268 Rp. 5,087
8 Santi Bidan 8
Gol.-
ANC Rp. 358,020 Rp. 358,020
PNC Rp. 169,065 Rp. 169,065
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
9 Fajrin Bidan 9
Gol.-
emergn.Dsr
ANC Rp. 119,340 Rp. 119,340
PNC Rp. 188,955 Rp. 188,955
Pasang IUD
Pasang Implant
Suntik KB
Pra Rujukan
Transport Rujukan
JUMLAH Rp. 21,226,000 Rp. 551,863 Rp. 17,527,725 Rp. 100,190 ###
Penanggungjawab Bojonegoro, 2013


NIP.197308172002121003 NIP.198108262010012001
Mengetahui/setuju
KPA Kegiatan
dibayar
Penyediaan Biaya Operasional
Mengetah Lunas dibayar
Lunas tgl……………….
Dibayar Tgl…………..
KPAui/setuju
Kegiatan
dan Pemeliharaan Pejabat Pelaksana Teknik
Pejabat Pelaksana Bendahara Pengeluaran Pembantu
Bendahara Pengeluaran Pembantu
Penyediaan
dibayarBiaya Teknik
Operasional
KPA dan Kegiatan ( PPTK )
Pemeliharaan
Kegiatan
Penyediaa SRI WIDJIATI, SE.
n Biaya NIP. 19631201 200112 2 001
Operasion RUDI EKO
BAMBANG
al dan PRASETYO, S.Psi.
SURYANTO,
PemeliharSH NIP. 19770304 200312
dibayar
Mengetah Lunas dibayar tgl……………….
KPAui/setuju
Kegiatan Pejabat Pelaksana Bendahara Pengeluaran Pembantu
Penyediaan
dibayarBiaya Teknik )Kegiatan (PPTK'
Operasional
KPA dan
Mengetahui/setuju Kegiatan ( PPTK )
Pemeliharaan
Kegiatan
dibayar Rahmad,Msi
Dr.Syaiful Purwani Pujiastuti,SKM Pristiya
SRI Maulaningrum,SKM
WIDJIATI, SE.
Penyediaa
KPA Kegiatan
NIP.196302191989031006 NIP.197710102006042041 NIP.198412162011012015
NIP. 19631201 200112 2 001
n Biaya
Penyediaan Biaya
Operasion dan
Operasional RUDI EKO
BAMBANG
al dan
Pemeliharaan PRASETYO, S.Psi.
SURYANTO,
PemeliharSH NIP. 19770304 200312
NIP. 19660809
aan 1 004
198803 1 010
BAMBANG
SURYANTO, SH
NIP. 19660809
BAMBAN
198803 1 010
G
SURYANT
O, SH
NIP.
19660809
198803 1
010
bantu
BAGIAN BULAN : DESEMBER
PUSKESMAS : NGASEM
BEBAN ANGGARAN : PAPBD KABUPATEN BOJONEGORO
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Dua Juta Enam Ratus Empat Puluh Tiga Ribu Sembilan Ratus
Delapan Puluh Lima Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 66,794
Rp 54,649
JUMLAH Rp. 2,643,985 Rp. 35,739 Rp. 2,608,246

NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan
MengetahPenyediaan Biaya Operasional Lunas Dibayar Tgl…………..
dan Pemeliharaan
ui/setuju Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
dibayar )Kegiatan (PPTK'
KPA
Kegiatan
Dr.Syaiful Rahmad,Msi Purwani Pujiastuti,SKM Pristiya Maulaningrum,SKM
Penyediaa
NIP.196302191989031006 NIP.197710102006042041 NIP.198412162011012015
n Biaya
Operasion
al dan
Pemelihar
aan
BAMBAN
G
SURYANT
O, SH
NIP.
19660809
198803 1
010
351750
mbantu
PUSKESMAS : NGASEM
BEBAN ANGGARAN : PAPBD KABUPATEN BOJONEGORO
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Lima Ratus Dua Ribu Empat Ratus Dua Puluh Delapan Rupiah
dengan rincian :
No Unsur
1 2 3 5 7 8 9
Rp. 91,908 5
Rp 91,908
JUMLAH Rp. 502,428 Rp. 33,393 Rp. 469,035


NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan
Mengetah Penyediaan Biaya Operasional Lunas Dibayar Tgl…………..
dan Pemeliharaan
ui/setuju Pejabat Pelaksana Teknik Bendahara Pengeluaran Pembantu
dibayar )Kegiatan (PPTK'
KPA
Kegiatan
Dr.Syaiful Rahmad,Msi Purwani Pujiastuti,SKM Pristiya Maulaningrum,SKM
Penyediaa
NIP.196302191989031006 NIP.197710102006042041 NIP.198412162011012015
n Biaya
Operasion
al dan
Pemelihar
aan
BAMBAN
G
SURYANT
O, SH
NIP.
19660809
198803 1
010
60 1 1
8 8
5 5
2 2
4 4
bantu
PUSKESMAS : NGASEM
KODE REKENING : 1.02.1.02.01.16.13.5.2.1.01.06
TERBILANG : Satu Juta Delapan Puluh Ribu Dua Ratus Delapan Belas Rupiah
dengan rincian :
1 2 3 5 7 8 9
14
Rp 66,794
Rp 54,649
JUMLAH Rp. 2,643,985 Rp. 14,602 Rp. 1,065,616

NIP.197308172002121003 NIP.198108262010012001
KPA Kegiatan Penyediaan Biaya Lunas dibayar
Operasional dan Pemeliharaan Pejabat Pelaksana Teknik tgl……………….
Kegiatan ( PPTK ) Bendahara Pengeluaran
Pembantu
BAMBANG SURYANTO, SH
NIP. 19660809 198803 1 010 RUDI EKO PRASETYO,
S.Psi. SRI WIDJIATI, SE.
KPA Kegiatan Penyediaan Biaya Lunas dibayar
Operasional dan Pemeliharaan Pejabat Pelaksana Teknik tgl……………….
Kegiatan ( PPTK ) Bendahara Pengeluaran
Pembantu
BAMBANG SURYANTO, SH
NIP. 19660809 198803 1 010 RUDI EKO PRASETYO,
S.Psi. SRI WIDJIATI, SE.
NIP. 19770304 200312 1 NIP. 19631201 200112 2 001
004
BOJONEGORO
Tanda Tangan
9
351750
bayar
……….
engeluaran
ntu
ATI, SE.
bayar
……….
engeluaran
ntu
ATI, SE.
00112 2 001

SPJ Persalinan Jampersal 2013

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CARA PENGHITUNGAN REMUNERASI JAMPERSAL

JUMLAH Rp. 9,966,000 Rp. 229,455 #REF! Rp. 191,081 #REF!

AGUS PUTRA PETIR

Mengetahui/setuju dibayar Pejabat Pelaksana Teknik Lunas dibayar tgl……………….

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. SRI WIDJIATI, SE.

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi. SRI WIDJIATI, SE.

No. Nama / Golongan Jabatan Remunerasi PPH Diterima Tanda Tangan

3 Indah Dewi Buana Bidan Rp -

dr. ANUGRAH ILAHI

Mengetahui/setuju dibayar Lunas dibayar tgl……………….

SRI WIDJIATI, SE.

2 Indah Dewi Buana Bidan Koord.

dr. ANUGRAH ILAHI AGUS PUTRA PETIR

Lunas dibayar tgl……………….

SRI WIDJIATI, SE.

1 dr.Agust Fariono Kapus 1

Penanggungjawab Bojonegoro,03 April 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

Penanggungjawab Bojonegoro,03 April 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI,SE

1 dr.Agust Fariono Kapus 1

2 dr.Tri Vera Handayani Dokter 2

ANC Rp 780,000 Rp. 39,000 Rp. 70,200 3,510 Rp. 90,031

Penanggungjawab Bojonegoro,03 Mei 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

Penanggungjawab Bojonegoro,03 Mei 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI,SE

ANC Rp 936,000 Rp. 46,800 Rp. 84,240 4,212 Rp. 90,031

Penanggungjawab Bojonegoro,03 Juni 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

Penanggungjawab Bojonegoro,03 Juni 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI,SE

Dinkes Jaspel Langsung

1 dr.Agust Fariono Kapus 1

ANC Rp 1,248,000 Rp. 62,400 Rp. 112,320 5,616 Rp. 90,031

Penanggungjawab Bojonegoro,03 Juli 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

Penanggungjawab Bojonegoro,03 Juli 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH RUDI EKO PRASETYO, S.Psi SRI WIDJIATI,SE

1 dr.Agust Fariono Kapus 1

ANC Rp 1,443,000 Rp. 71,550 Rp. 129,870 6,494 Rp. 90,031

ANC Rp. 208,845 Rp. 208,845

ANC Rp. 29,835 Rp. 29,835

ANC Rp. 278,460 Rp. 278,460

ANC Rp. 29,835 Rp. 29,835

ANC Rp. 99,450 Rp. 99,450

Penanggungjawab Bojonegoro,03 Agustus 2013

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

Mengetahui/setuju dibayar dibayar

dr.H.M.AGUST FARIONO dr.TRI VERA HANDAYANI

BAMBANG SURYANTO, SH SRI WIDJIATI, SE.

Penanggungjawab Bojonegoro,03 Agustus 2013