Budget

Modul Intervention
Line

Differentiated HIV Testing

Mobile MSM 26 Community-based testing
Services

FGD MSM 25 Prevention Community empowerment

Differentiated HIV Testing

Mobile TG 24 Community-based testing
Services

FGD TG 12 Prevention Community empowerment

Differentiated HIV Testing

DTD 142 Community-based testing
Services

FGD PWD 46 Prevention Community empowerment

Differentiated HIV Testing

Mobile PWID 50 Community-based testing
Services
Activity Description Cost input ProjectNO = BL

MSM Mobile clinics for HIV testing and STI 2.4 Meeting/Advocacy related per
201.02.BL-026
service at district diems/transport/other costs

Community Mobilization for MSM

2.1 Training related per
Community to Improve BCC (Medium and 102.04.BL-025
diems/transport/other costs
Basic Districts selected)

TG Mobile clinics for HIV testing and STI 2.4 Meeting/Advocacy related per
201.01.BL-024
service at district diems/transport/other costs

Community Mobilization for TG

2.1 Training related per
Community to Improve BCC (medium and 102.02.BL-012
diems/transport/other costs
basic district selected)

HCT Proactive Approach to find Hard To

2.4 Meeting/Advocacy related per
Reach KAPs (door to door) at MSM-TG 201.17.BL-142
diems/transport/other costs
Medium and basic district

Support Group Meeting for PWID, 2.4 Meeting/Advocacy related per

102.06.BL-046
partners, Young PWID diems/transport/other costs

2.4 Meeting/Advocacy related per

Mobile testing for PWID and Partner 201.04.BL-050
diems/transport/other costs
 CASH ADVANCE REQUISITION
(PERMINTAAN UANG MUKA)

Tanggal : 27 Januari 2022

Kepada : Finance & Administration Officer
Nama Pemohon/Divisi : Mufti Tubagus M

Mengajukan Uang Muka : Rp 1,350,000

(Satu juta tiga ratus lima puluh ribu rupiah)
Modul : Differentiated HIV Testing Services
Budget Line : 201.02.BL-026
Kegiatan : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : 28-Jan-22
Tempat Pelaksanaan : Adem Ayem - Jatibarang

Rencana Operasional Kegiatan

No Uraian Unit Cost Person Hari Total
1 Konsumsi (Lunch) Rp 35,000 30 1 1,050,000
2 Transport for Healh Services Rp 100,000 3 1 300,000

Jumlah 1,350,000

Keterangan Nama Tanggal Tandatangan

Pemohon Mufti Tubagus M 27-Jan-22

Verifikasi F & A Indah Uswatun Hasanah 27-Jan-22

Koordinator SSR Agus, S.H 27-Jan-22

Catatan:
1. Uang muka ini harus dipertanggungkawabkan dalam jangka waktu 5 (lima) hari kerja setelah kegiatan selesai dilaksanakan.
2. Apabila uang muka sebelumnya belum dapat dipertanggungjawabkan, maka tidak berhak atas permintaan uang muka berikutnya.
 Laporan Pertanggungjawaban

Modul : Differentiated HIV Testing Services

Budget Line : 201.02.BL-026
Intervention : Community-based testing
Cost Input : 2.4 Meeting/Advocacy related per diems/transport/other costs
Aktivitas : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : 28-Jan-2022
Tempat Pelaksanaan : Adem Ayem - Jatibarang

Uraian Uang Muka: Jumlah

Jumlah uang muka yang diterima Rp 1,350,000

Uraian pengeluaran biaya:

No. Uraian Jumlah
1 Konsumsi (Lunch) Rp 1,050,000
2 Transport for Healh Services Rp 300,000

Total Pengeluaran Rp 1,350,000

Selisih lebih/kurang (dikembalikan ke/diterima dari kasir/Bank) Rp -

Cirebon, 25 Januari 2022

Dibuat Oleh: Diperiksa Oleh: Disetujui Oleh:

(Yudi Taryudi) (Indah Uswatun Hasanah) (Agus, S.H)

PIC Finance & Administrasi Koordinator SSR
Modul : Differentiated HIV Testing Services
Budget Line : 201.02.BL-026
Kegiatan : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : Friday, January 28, 2022
Tempat Pelaksanaan : Adem Ayem - Jatibarang

DAFTAR HADIR PESERTA

Cirebon, 18 Januari 2022

No. Nama No Telepon Alamat Tanda Tangan

7
8

10

11

12

13

14

15

16

17

18

19

20
21

22

23

24

25

26

27

28

29

30
Modul : Differentiated HIV Testing Services
Budget Line : 201.02.BL-026
Kegiatan : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : Friday, January 28, 2022
Tempat Pelaksanaan : Adem Ayem - Jatibarang

DAFTAR HADIR LAYANAN

Cirebon, 18 Januari 2022

No. Nama No Telepon Instansi Tanda Tangan

3
Modul : Differentiated HIV Testing Services
Budget Line : 201.02.BL-026
Kegiatan : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : Friday, January 28, 2022
Tempat Pelaksanaan : Adem Ayem - Jatibarang

TANDA TERIMA TRANSPORT

Cirebon, 18 Januari 2022

No. Nama No Telepon Nominal Transport Tanda Tangan

1 Rp 100,000

2 Rp 100,000

3 Rp 100,000

Total Rp 300,000

Yang Menyerahkan, Diketahui Oleh :

Indah Uswatun Hasanah Agus, S.H

Keuangan SSR Koordinator SSR

 LAPORAN KEGIATAN
Modul : Differentiated HIV Testing Services
Cost Input : 2.4 Meeting/Advocacy related per diems/transport/other costs
Intervention : Community-based testing
Budget Line : 201.02.BL-026
Kegiatan : MSM Mobile clinics for HIV testing and STI service at district
Tanggal Pelaksanaan : Friday, January 28, 2022
Tempat Pelaksanaan : Adem Ayem - Jatibarang

1 Pokok Bahasan

2 Proses Kegiatan

3 Hasil Pertemuan

4 Kesimpulan

Cirebon, 2022
Penanggung Jawab Kegiatan

Mufti Tubagus M
Koordinator Lapangan
 Makan : (35.000 * 21) 735,000
Snack : (15.000 * 21) 315,000
Fee Fasilitator : (300.000 * 1) 300,000
FGD TG
Transport Fasilitator : (100.000 * 1) 100,000
Transport Peserta : (100.000 * 20) 2,000,000
Total 3,450,000

Makan (35.000 * 26) 910,000

Snack : (15.000 * 26) 390,000
Fee Fasilitator : (300.000 * 1) 300,000
FGD MSM
Transport Fasilitator : (100.000 * 1) 100,000
Transport Peserta : (100.000 * 25) 2,500,000
Total 4,200,000

Makan : (35.000 * 30) 1,050,000

Mobile MSM Transport Layanan (100.000 * 3) 300,000
Total 1,350,000

DTD Transport Layanan (100.000 * 5) 500,000

Makan : (35.000 * 21) 735,000

Snack : (15.000 * 21) 315,000
Fee Fasilitator : (300.000 * 1) 300,000
PWID Meeting
Transport Fasilitator : (100.000 * 1) 100,000
Transport Peserta : (100.000 * 20) 2,000,000
Total 3,450,000

Snack Peserta : (15.000 * 20) 300,000

Snack Layanan : (15.000 * 5) 75,000
Mobile PWID
Transport Layanan (100.000 * 5) 500,000
Total 875,000
Susunan Laporan/Kelengkapan
FGD MSM/TG/PWID
1 Tor
2 Surat
3 Absen Peserta
4 Tanda Terima Transport Peserta
5 Absen Fasilitator/Narsum
6 Tanda Terima Fee & Transport Fasilitator/Narsum
7 Biodata Fasilitator/Narsum
8 Suat Tugas Fasilitator/Narsum
9 Nota Konsumsi
10 Foto
11 Laporan Kegiatan/Narasi

Mobile MSM/TG/PWID
1 Tor
2 Surat
3 Absen Peserta
4 Absen Layanan
5 Tanda Terima Transport Layanan
6 Nota Konsumsi
7 Foto
8 Laporan Kegiatan/Narasi

Door to Door
1 Tor
2 Surat
3 Absen Peserta
4 Bukti Fc Reff 03
5 Absen Layanan
6 Berita Acara Penerima Transport Layanan
7 Bukti Transfer
8 Foto
9 Laporan Kegiatan/Narasi