YANG ADA

Polindes
NO NAMA ALAT

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1 2 3
1 Doppler 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 HB Meter Digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Inkubator sederhana 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lampu periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Lemari Obat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Lemari Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Meja Instrumen/Alat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Meja Periksa Ginekologi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Kursi stool pemeriksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Meja Resusitasi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Pelvimeter Obstetrik/Jangka Panggul 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Pengukur Panjang Badan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pispot 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Resusitasi set terdiri dari:
a. Resusitasi Bayi beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Resusitasi Dewasa beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15 Spekulum Vagina Set terdiri dari:
a. Spekulum Vagina (Cocor Bebek) Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Spekulum Vagina (Cocor Bebek) Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c. Spekulum Vagina (Cocor Bebek) Sedang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
d. Spekulum Vagina (Sims) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Sphygmomanometer (Tensimeter) Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Sphygmomanometer anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Stand Lamp untuk tindakan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Standar infus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Sterilisator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Stetoskop Set terdiri dari: 1 1 1 1 1 1
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Tabung O2 1m3 Lengkap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Tempat Tidur Periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Timbangan + Pengukur tinggi badan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Timbangan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
26 Tromol Kasa/Kain Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
27 Kulkas (penyimpan reagen, vaksin dan obat) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 Kursi Tunggu Pasien 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
29 Kursi Kerja 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
30 Meja Tulis ½ biro 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
31 KIT BIDAN
1/2 Klem Korcher/ Pemecah Ketuban 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir DeLee / Bulb 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir Elektrik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Aritimer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bak Instrumen dengan tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Baki Logam Tempat Alat Steril Bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

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Ponkesdes 13
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Ponkesdes 18
Bengkok Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bengkok Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Benang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Episiotomi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean/ Klem Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korcher Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korentang, Penjepit Sponge (Foerster) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lampu senter untuk periksa/pen light 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mangkok untuk Larutan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Refleks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pemeriksaan Hb/HB Sahli 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Lingkar Kepala 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Tinggi Badan (Microtoise) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penjepit Uterus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penutup Mata (Okluder)/Kaca Mata Google 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Panjang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Pendek 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Bedah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pisau Pencukur 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pita Pengukur Lila 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Silinder Korentang Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde mulut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde Uterus/Penduga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Janin/Funduscope 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 12 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 16,5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tabung untuk bilas vagina 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tampon Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas Bidan Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dahi dan Telinga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Thermometer digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan 7 kg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Toples Kapas / Kasa Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Torniket Karet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Cekung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handuk Kecil untuk Lap Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat untuk Membersihkan Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Steek Laken (Sprei Kecil) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
32 HECTING SET
Bak Instrumen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Bedah Metzenbaum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

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Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Chirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Needle Holder 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Probe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Scalpel Handle No. 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
34 BAHAN HABIS PAKAI
Benang Silk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Betadine Solution atau Desinfektan lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Chromic Catgut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 1 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 10 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 3 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 5 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 10 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 14 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pelilit Kapas/Cotton Aplicator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sabun Tangan atau Sabun Cair Antiseptik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Selang Karet untuk Anus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Semprit, Gliserin 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Skalpel, Mata Pisau Bedah (Nomor 10) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kotak Penyimpan Jarum Bekas/Safety Box 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tempat sampah injak bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

35 Pencatatan & Pelaporan

Buku register pelayanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir Informed Consent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir lainnya sesuai kebutuhan pelayanan yang diberikan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir laporan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir rujukan ke Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

SET PERALATAN PHN

1 Alat Test Darah Portable/rapid diagnostic test (Gula darah, 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Asam Urat, Kolesterol)
2 Sphygmomanometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Sphygmomanometer Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Stetoskop Set terdiri dari:
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 CHN Kit
Bak Instrumen dilengkapi Tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Angkat Jahitan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Iris Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Jaringan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Arteri 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

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Kom Iodine 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom Kapas Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom dilengkapi tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Nierbeken 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Reflex 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Cirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip Lidah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Peak Flow Meter 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pen lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penlight 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Badan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Biasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Bolong 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas CHN Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Bahan Habis Pakai Peralatan PHN
Alat tenun perawatan luka 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol 70% kemasan botol 100 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol Swab kemasan box isi 100 lembar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Blood Lancet kemasan box isi 25 buah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handscrub kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kasa hidrofil steril uk 16 cm x 16 cm kemasan dos isi 16 lbr 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NaCl 0,9 % kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pembalut (gulung) hidrofil 4 m x 5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Plester 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Povidon Iodida larutan 10% kemasan botol 60 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Asam Urat kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Glukosa kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Haemoglobin Darah kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Kolesterol kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Rivanol kemasan botol 300 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Non Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jumlah
peralatan
yg ada di
semua
Ponkes-
des
4
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
Jumlah
peralatan
yg ada di
semua
Ponkes-
des
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
Jumlah
peralatan
yg ada di
semua
Ponkes-
des
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0

0
0

0
0
0

0
0
0
0
0
0
Jumlah
peralatan
yg ada di
semua
Ponkes-
des
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
YANG BERFUNGSI

Polindes
NO NAMA ALAT Jml alat

Ponkesdes 1
Ponkesdes 2
Ponkesdes 3
Ponkesdes 4
Ponkesdes 5
Ponkesdes 6
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Ponkesdes 15
Ponkesdes 16
Ponkesdes 17
Ponkesdes 18
yang
berfungsi
di semua
Ponkes-
des
1 2 3 4
1 Doppler 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 HB Meter Digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Inkubator sederhana 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lampu periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Lemari Obat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Lemari Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Meja Instrumen/Alat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Meja Periksa Ginekologi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Kursi stool pemeriksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Meja Resusitasi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Pelvimeter Obstetrik/Jangka Panggul 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Pengukur Panjang Badan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pispot 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Resusitasi set terdiri dari:
a. Resusitasi Bayi beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Resusitasi Dewasa beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15 Spekulum Vagina Set terdiri dari:
a. Spekulum Vagina (Cocor Bebek) Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Spekulum Vagina (Cocor Bebek) Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c. Spekulum Vagina (Cocor Bebek) Sedang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
d. Spekulum Vagina (Sims) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Sphygmomanometer (Tensimeter) Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Sphygmomanometer anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Stand Lamp untuk tindakan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Standar infus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Sterilisator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Stetoskop Set terdiri dari: 1 1 1 1 1 1
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Tabung O2 1m3 Lengkap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Tempat Tidur Periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Timbangan + Pengukur tinggi badan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Timbangan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
26 Tromol Kasa/Kain Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
27 Kulkas (penyimpan reagen, vaksin dan obat) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 Kursi Tunggu Pasien 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
29 Kursi Kerja 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
30 Meja Tulis ½ biro 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
31 KIT BIDAN
1/2 Klem Korcher/ Pemecah Ketuban 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir DeLee / Bulb 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir Elektrik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Aritimer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bak Instrumen dengan tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Baki Logam Tempat Alat Steril Bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT Jml alat

Ponkesdes 1
Ponkesdes 2
Ponkesdes 3
Ponkesdes 4
Ponkesdes 5
Ponkesdes 6
Ponkesdes 7
Ponkesdes 8
Ponkesdes 9
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Ponkesdes 14
Ponkesdes 15
Ponkesdes 16
Ponkesdes 17
Ponkesdes 18
yang
berfungsi
di semua
Ponkes-
des
Bengkok Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bengkok Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Benang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Episiotomi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean/ Klem Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korcher Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korentang, Penjepit Sponge (Foerster) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lampu senter untuk periksa/pen light 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mangkok untuk Larutan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Refleks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pemeriksaan Hb/HB Sahli 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Lingkar Kepala 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Tinggi Badan (Microtoise) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penjepit Uterus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penutup Mata (Okluder)/Kaca Mata Google 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Panjang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Pendek 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Bedah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pisau Pencukur 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pita Pengukur Lila 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Silinder Korentang Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde mulut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde Uterus/Penduga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Janin/Funduscope 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 12 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 16,5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tabung untuk bilas vagina 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tampon Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas Bidan Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dahi dan Telinga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Thermometer digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan 7 kg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Toples Kapas / Kasa Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Torniket Karet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Cekung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handuk Kecil untuk Lap Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat untuk Membersihkan Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Steek Laken (Sprei Kecil) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
32 HECTING SET
Bak Instrumen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Bedah Metzenbaum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT Jml alat

Ponkesdes 1
Ponkesdes 2
Ponkesdes 3
Ponkesdes 4
Ponkesdes 5
Ponkesdes 6
Ponkesdes 7
Ponkesdes 8
Ponkesdes 9
Ponkesdes 10
Ponkesdes 11
Ponkesdes 12
Ponkesdes 13
Ponkesdes 14
Ponkesdes 15
Ponkesdes 16
Ponkesdes 17
Ponkesdes 18
yang
berfungsi
di semua
Ponkes-
des
Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Chirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Needle Holder 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Probe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Scalpel Handle No. 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
34 BAHAN HABIS PAKAI
Benang Silk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Betadine Solution atau Desinfektan lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Chromic Catgut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 1 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 10 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 3 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 5 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 10 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 14 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pelilit Kapas/Cotton Aplicator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sabun Tangan atau Sabun Cair Antiseptik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Selang Karet untuk Anus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Semprit, Gliserin 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Skalpel, Mata Pisau Bedah (Nomor 10) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kotak Penyimpan Jarum Bekas/Safety Box 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tempat sampah injak bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

35 Pencatatan & Pelaporan

Buku register pelayanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir Informed Consent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir lainnya sesuai kebutuhan pelayanan yang diberikan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir laporan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir rujukan ke Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

SET PERALATAN PHN

1 Alat Test Darah Portable/rapid diagnostic test (Gula darah, 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Asam Urat, Kolesterol)
2 Sphygmomanometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Sphygmomanometer Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Stetoskop Set terdiri dari:
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 CHN Kit
Bak Instrumen dilengkapi Tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Angkat Jahitan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Iris Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Jaringan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Arteri 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT Jml alat

Ponkesdes 1
Ponkesdes 2
Ponkesdes 3
Ponkesdes 4
Ponkesdes 5
Ponkesdes 6
Ponkesdes 7
Ponkesdes 8
Ponkesdes 9
Ponkesdes 10
Ponkesdes 11
Ponkesdes 12
Ponkesdes 13
Ponkesdes 14
Ponkesdes 15
Ponkesdes 16
Ponkesdes 17
Ponkesdes 18
yang
berfungsi
di semua
Ponkes-
des
Kom Iodine 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom Kapas Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom dilengkapi tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Nierbeken 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Reflex 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Cirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip Lidah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Peak Flow Meter 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pen lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penlight 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Badan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Biasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Bolong 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas CHN Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Bahan Habis Pakai Peralatan PHN
Alat tenun perawatan luka 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol 70% kemasan botol 100 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol Swab kemasan box isi 100 lembar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Blood Lancet kemasan box isi 25 buah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handscrub kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kasa hidrofil steril uk 16 cm x 16 cm kemasan dos isi 16 lbr 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NaCl 0,9 % kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pembalut (gulung) hidrofil 4 m x 5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Plester 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Povidon Iodida larutan 10% kemasan botol 60 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Asam Urat kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Glukosa kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Haemoglobin Darah kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Kolesterol kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Rivanol kemasan botol 300 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Non Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
 BUKU INVENTARIS PERALATAN PONKESD
PUSKESMAS DIISI NAMA PUSKESM

NO NAMA ALAT

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1 2 A R A R A R A R A R A R A R A R A
1 Doppler 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
2 HB Meter Digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Inkubator sederhana 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Lampu periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 Lemari Obat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Lemari Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
7 Meja Instrumen/Alat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
8 Meja Periksa Ginekologi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
9 Kursi stool pemeriksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
10 Meja Resusitasi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
11 Pelvimeter Obstetrik/Jangka Panggul 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
12 Pengukur Panjang Badan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
13 Pispot 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
14 Resusitasi set terdiri dari:
a. Resusitasi Bayi beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Resusitasi Dewasa beserta masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
15 Spekulum Vagina Set terdiri dari:
a. Spekulum Vagina (Cocor Bebek) Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
b. Spekulum Vagina (Cocor Bebek) Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
c. Spekulum Vagina (Cocor Bebek) Sedang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
d. Spekulum Vagina (Sims) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
16 Sphygmomanometer (Tensimeter) Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
17 Sphygmomanometer anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
18 Stand Lamp untuk tindakan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
19 Standar infus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
20 Sterilisator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
21 Stetoskop Set terdiri dari: 1 1 1 1 1 1
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
22 Tabung O2 1m3 Lengkap 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
23 Tempat Tidur Periksa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
24 Timbangan + Pengukur tinggi badan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
25 Timbangan Bayi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
26 Tromol Kasa/Kain Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
27 Kulkas (penyimpan reagen, vaksin dan obat) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
28 Kursi Tunggu Pasien 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
29 Kursi Kerja 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
30 Meja Tulis ½ biro 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
31 KIT BIDAN
1/2 Klem Korcher/ Pemecah Ketuban 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir DeLee / Bulb 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alat Penghisap Lendir Elektrik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Aritimer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bak Instrumen dengan tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Baki Logam Tempat Alat Steril Bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bengkok Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Bengkok Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

Ponkesdes 1

Ponkesdes 2

Ponkesdes 3

Ponkesdes 4

Ponkesdes 5

Ponkesdes 6

Ponkesdes 7

Ponkesdes 8

Ponkesdes 9
Gunting Benang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Episiotomi 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean/ Klem Tali Pusat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korcher Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Korentang, Penjepit Sponge (Foerster) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lampu senter untuk periksa/pen light 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Mangkok untuk Larutan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Refleks 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pemeriksaan Hb/HB Sahli 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Lingkar Kepala 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pengukur Tinggi Badan (Microtoise) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penjepit Uterus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penutup Mata (Okluder)/Kaca Mata Google 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Panjang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomi Pendek 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Bedah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pisau Pencukur 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pita Pengukur Lila 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Silinder Korentang Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde mulut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sonde Uterus/Penduga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Janin/Funduscope 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 12 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip lidah logam panjang 16,5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tabung untuk bilas vagina 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tampon Tang 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas Bidan Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dahi dan Telinga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Thermometer digital 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan 7 kg 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Toples Kapas / Kasa Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Torniket Karet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Waskom Cekung 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handuk Kecil untuk Lap Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sikat untuk Membersihkan Peralatan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Steek Laken (Sprei Kecil) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
32 HECTING SET
Bak Instrumen 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Pean Bengkok 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Bedah Metzenbaum 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Chirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Needle Holder 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Probe 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

Ponkesdes 1

Ponkesdes 2

Ponkesdes 3

Ponkesdes 4

Ponkesdes 5

Ponkesdes 6

Ponkesdes 7

Ponkesdes 8

Ponkesdes 9
Scalpel Handle No. 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
34 BAHAN HABIS PAKAI
Benang Silk 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Betadine Solution atau Desinfektan lainnya 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Chromic Catgut 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 1 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 10 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 3 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Disposable Syringe, 5 cc 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 1/2 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Bulat 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Jarum Jahit, Lengkung, 3/8 Lingkaran, Penampang Segitiga 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 10 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kateter, Karet Nomor 14 (Nelaton) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pelilit Kapas/Cotton Aplicator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sabun Tangan atau Sabun Cair Antiseptik 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Selang Karet untuk Anus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Semprit, Gliserin 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Skalpel, Mata Pisau Bedah (Nomor 10) 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kotak Penyimpan Jarum Bekas/Safety Box 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tempat sampah injak bertutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

35 Pencatatan & Pelaporan

Buku register pelayanan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir Informed Consent 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir lainnya sesuai kebutuhan pelayanan yang diberikan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir laporan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Formulir rujukan ke Puskesmas 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

SET PERALATAN PHN

1 Alat Test Darah Portable/rapid diagnostic test (Gula darah, 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Asam Urat, Kolesterol)
2 Sphygmomanometer Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
3 Sphygmomanometer Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
4 Stetoskop Set terdiri dari:
Stetoskop Anak 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Stetoskop Neonatus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
5 CHN Kit
Bak Instrumen dilengkapi Tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Angkat Jahitan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Iris Lurus 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Jaringan 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Gunting Verband 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Klem Arteri 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom Iodine 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom Kapas Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kom dilengkapi tutup 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Nierbeken 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Palu Reflex 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pinset Anatomis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NO NAMA ALAT

Ponkesdes 1

Ponkesdes 2

Ponkesdes 3

Ponkesdes 4

Ponkesdes 5

Ponkesdes 6

Ponkesdes 7

Ponkesdes 8

Ponkesdes 9
Pinset Cirurgis 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sudip Lidah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Peak Flow Meter 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pen lancet 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Penlight 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Termometer 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Timbangan Badan Dewasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Meteran 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Biasa 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Duk Bolong 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Besar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Perlak Kecil 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Tas CHN Kit 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
6 Bahan Habis Pakai Peralatan PHN
Alat tenun perawatan luka 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol 70% kemasan botol 100 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Alkohol Swab kemasan box isi 100 lembar 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Blood Lancet kemasan box isi 25 buah 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Handscrub kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Kasa hidrofil steril uk 16 cm x 16 cm kemasan dos isi 16 lbr 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Masker 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
NaCl 0,9 % kemasan botol 500 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pembalut (gulung) hidrofil 4 m x 5 cm 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Plester 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Povidon Iodida larutan 10% kemasan botol 60 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Asam Urat kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Glukosa kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Haemoglobin Darah kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Refill Strip Kolesterol kemasan isi 25 strip 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Rivanol kemasan botol 300 ml 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Non Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Sarung Tangan Steril 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0%
0 0%
0 0%
0 0%
0 0%
0 0%
0 0%
0 0%
0 0%

Mengetahui
Kepala Puskesmas
DIISI NAMA PUSKESMAS

DIISI NAMA KAPUS

NIP.
BUKU INVENTARIS PERALATAN PONKESDES
DIISI NAMA PUSKESMAS

POLINDES

Ponkesdes 9

Ponkesdes

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Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

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10

11

12

13

14

15

16

17

18
R A R A R A R A R A R A R A R A R A R
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
1 1 1 1 1 1
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ponkesdes 9

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10

11

12

13

14

15

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17

18
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ponkesdes 9

Ponkesdes

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Ponkesdes

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Ponkesdes

Ponkesdes
10

11

12

13

14

15

16

17

18
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Ponkesdes 9

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes

Ponkesdes
10

11

12

13

14

15

16

17

18
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

0 0%
0 0%
0 0%
0 0%
0 0%
0 0% 0 0%
0 0%
0 0%
0
Penanggung Jawab
Peralatan Kesehatan

DIISI NAMA PENGURUS BARANG

NIP/NRPTT