Format Pengisian Lampiran II PKM Nipah

Nama Instansi : UPT BLUD PKM Nipah
No NIK
1 Ni.Nyoman Astuti Ariastini 5208014404810003

5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
5208014404810003
2 AHMAD JAENI 5208050502910001
5208050502910001
5208050502910001
5208050502910001
5208050502910001
3 Baiq Hajjah Hulfah Mustikamah 5208055805910001
5208055805910001
5208055805910001
5208055805910001
4 DINA WAHYU SRIANA 5208055605920001
5208055605920001
5 Syits Imaduddin 5205010604890001
5205010604890001
5205010604890001
5205010604890001
5205010604890001
5205010604890001
6 BAIQ WILLIA ILMIAWATININGSIH 5104035807910003
5104035807910003
5104035807910003
5104035807910003
5104035807910003
5104035807910003
5104035807910003
7 Geri Anggreni 5208055804930002
5208055804930002
5208055804930002
5208055804930002
5208055804930002
5208055804930002
8 Hamsatun 5208053112810044
5208053112810044
5208053112810044
5208053112810044
5208053112810044
5208053112810044
5208053112810044
5208053112810044
5208053112810044
9 Hendra Budi Eltari 5203110601930002
5203110601930002
5203110601930002
5203110601930002
5203110601930002
10 Wawan Kurniawan 520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
520805041090001
11 Sartika Rillanda 5208054501920008
5208054501920008
5208054501920008
5208054501920008
5208054501920008
5208054501920008
12 Nanik Umiati 5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
5208055301920001
13 Zuryati 5208056003910004
5208056003910004
5208056003910004
5208056003910004
14 zaetun 5271047112880086
5271047112880086
5271047112880086
5271047112880086
15 megayati 5208026702910001
5208026702910001
5208026702910001
5208026702910001
5208026702910001
5208026702910001
16 Lilik fatmawati 5271066202920002
5271066202920002
5271066202920002
5271066202920002
5271066202920002
17 Murniati 5208055111900001
5208055111900001
5208055111900001
5208055111900001
5208055111900001
5208055111900001
18 APRILIANI RAHAYU KUSUMA WARDANI 5208055104930004
5208055104930004
5208055104930004
19 Ida Ayu Aprianti Windari 5208056104950004
5208056104950004
5208056104950004
5208056104950004
5208056104950004
20 Ida Bagus Putu Yoga Pradnyana 5104031202960001
5104031202960001
5104031202960001
21 Ira Wahyuni 5201144611960004
5201144611960004
5201144611960004
22 Jihan Jamil, AMd.Keb 520805590992002
520805590992002
520805590992002
23 Masitah 5208054101870004
5208054101870004
5208054101870004
24 Miptahul Jannah 5203064909940002
5203064909940002
5203064909940002
25 Mira Mardiana 5208055803950004
5208055803950004
5208055803950004
26 Naela Nazafitri 5208055907930002
5208055907930002
5208055907930002
27 Raehan Nurhidayati 5208050902950001
5208050902950001
5208050902950001
28 Rikawati 5208044609000001
5208044609000001
5208044609000001
29 Susanti 5203087112890061
5203087112890061
5203087112890061
30 SUHAELI 5208053112730040
5208053112730040
5208053112730040
RIWAYAT KONTRAK KERJA TENAGA NON ASN DAN E
Tanggal
Awal
Tanggal SK Tanggal Akhir Kerja
Nomor SK Kerja
(dd-mm-yyyy) (dd-mm-yyyy)
(dd-mm-
yyyy)
04.1/SPK/DIKES/I/DIKES/2022 1/3/2022 1/1/2022 12/31/2022

814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/04.a/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/32.b/01/DIKES/2017 1/9/2017 1/1/2017 12/31/2017
814/748.2/01/DIKES/2016 5/2/2016 1/1/2016 12/31/2016
191/01/DIKES/2015 1/5/2015 1/1/2015 12/31/2015
279/01/DIKES/2014 2/3/2014 1/1/2014 12/31/2014
434/01/DIKES/2013 2/11/2013 1/1/2013 12/31/2013
292/01/DIKES/2012 2/6/2012 1/1/2012 12/31/2012
250/01/DIKES/2011 2/14/2011 1/1/2011 12/31/2011
151/01/DIKES/2010 3/10/2010 1/1/2010 12/31/2010
361/01/Dikes/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/491.1/01/DIKES/2018 4/9/2018 4/1/2018 12/31/2018
361/01/SPK/Dikes/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/949.1/01/DIKES/2020 7/1/2020 7/1/2020 12/31/2020
11/01/PKM.N/I/2020 1/2/2020 1/1/2020 6/30/2020
503.1/SPK/DINKES/III/2022 3/1/2022 3/1/2022 12/31/2022
40.1/PKM.P/I/2020 1/2/2020 1/2/2020 12/31/2020
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/785/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/1943/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/685.3/01/DIKES/2017 5/2/2017 5/3/2017 12/31/2017
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/785/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 7/31/2020
814/949.1/01/DIKES/2020 8/3/2020 8/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 5/31/2019
814/715/01/DIKES/2019 6/10/2019 6/1/2019 5/31/2019
814/630.b/01/DIKES/2018 5/2/2018 5/1/2018 12/31/2018
361/01/SPK/Dikes/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/01.c/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/1503.a/01/DIKES/2017 10/2/2017 10/2/2017 12/31/2017
041/SPK/Dikes/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/04.e/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/87.A/01/DIKES/2017 1/9/2017 1/1/2017 12/31/2017
814/742.3/01/DIKES/2016 5/2/2016 1/1/2016 12/31/2016
201/01/DIKES/2015 1/5/2015 1/1/2015 12/31/2015
267/01/DIKES/2014 2/3/2014 1/1/2014 12/31/2014
041/SPK/Dikes/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/04.e/01/DIKES/2018 9/3/2018 9/1/2018 12/31/2018
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/04.d/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/87.c/01/DIKES/2017 1/9/2017 1/1/2017 12/31/2017
814/742.3/01/DIKES/2016 5/2/2016 1/1/2016 12/31/2016
200/01/DIKES/2015 1/5/2015 1/1/2015 12/31/2015
267/01/DIKES/2014 2/3/2014 1/1/2014 12/31/2014
434/01/DIKES/2013 2/11/2013 1/1/2013 12/31/2013
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/695.2/01/DIKES/2020 5/4/2020 5/1/2020 12/31/2020
07/01/PKM.N/I/2020 1/2/2020 1/2/2020 5/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/01.d/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/2/2019 1/1/2019 12/31/2019
814/04.d/01/DIKES/2018 1/2/2018 1/1/2018 12/31/2018
814/32.F/01/DIKES/2017 1/9/2017 1/1/2017 12/31/2017
814/743.4/01/DIKES/2016 5/2/2016 1/1/2016 12/31/2016
200/01/DIKES/2015 1/5/2015 1/1/2015 12/31/2015
267/01/DIKES/2014 2/3/2014 1/1/2014 12/31/2014
434/01/DIKES/2013 2/11/2013 1/1/2013 12/31/2013
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/481.4/01/DIKES/2019 4/1/2019 4/1/2019 12/31/2019
361/01/DIKES/II/2022 1/3/2022 1/3/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/481.4/01/DIKES/2019 4/1/2019 4/1/2019 12/31/2019
361/01/SPK/Dikes/II/2022 1/3/2022 1/1/2022 12/31/2022
814/15.1/01/DIKES/2021 1/4/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/2/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 5/2/2019 5/1/2019 12/31/2019
58.2/DIKES/1/2018 15/1/2018 1/1/2018 12/31/2018
33.a/DIKES/1/2017 1/10/2017 1/1/2017 12/31/2017
638/DIKES/I/2022 5/1/2022 2/1/2022 31/12/2022
533/DIKES/I/2021 2/1/2021 2/1/2021 31/12/2021
01/661/DIKES/1/2020 2/1/2020 2/1/2020 31/12/2020
814/2.1/01/DIKES/2019 2/1/2019 1/1/2019 31/12/2019
814/01.D/01/DIKES/2018 2/1/2018 1/1/2018 31/12/2018
361/01/SPK/Dikes/II/2022 1/3/2022 1/1/2022 12/31/2022
814/15.1/01/DIKES/2021 1/1/2021 1/1/2021 12/31/2021
814/56.2/01/DIKES/2020 1/1/2020 1/1/2020 12/31/2020
814/2.1/01/DIKES/2019 1/1/2019 5/1/2019 12/31/2019
814/04.a/01/DIKES/2018 1/1/2018 1/1/2018 12/31/2018
814/1503.a/01/DIKES/2017 10/2/2017 10/2/2017 12/31/2017
03.I/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
010/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
016/01/PKM.N/I/2020 1/2/2021 1/2/2021 31/12/2020
03.k/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
011/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
03/01/PKM.N/IX/2020 9/1/2020 9/1/2020 31/12/2020
200/060.A/I/2019 1/3/2018 1/1/2019 12/31/2019
800/03.4/I/2018 1/3/2018 1/1/2018 12/31/2018
03.j/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
013/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
014/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2020
03.m/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
017/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
012/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2020
03.a/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
023/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
09/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2020
03.c/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
022/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
013/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2022
03.b/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
03/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
014/01/PKM.N/IX/2020 1/2/2020 1/2/2020 31/12/2020
03.d/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
07/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
015/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2022
03.e/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
020/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
09/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2022
03.f/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
018/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021

018/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2022
03.g/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
01/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
02/01/PKM.N/IX/2020 1/2/2020 1/2/2020 31/12/2020
03.i/01/PKM.N/I/2022 1/3/2022 1/3/2022 31/12/2022
06/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021
019/01/PKM.N/I/2020 1/2/2020 1/2/2020 31/12/2020
1/3/2022 1/3/2022 31/12/2022
1/2/2021 1/2/2021 31/12/2021
1/2/2020 1/2/2020 31/12/2020
KERJA TENAGA NON ASN DAN EKS-THK-II
Jabatan
lnstansi Penempatan Unit Kerja Penempatan

Kode
Dinas Kesehatan Kab.Lombok Utara Puskesmas Nipah 4198499

Dinas Kesehatan Kab.Lombok Utara Puskesmas Pemenang 4198499
Dinas Kesehatan Kab.Lombok Utara Puskesmas Bayan 3031021
Dinas Kesehatan Kab.Lombok Utara Puskesmas Gangga 3031021
Dinas Kesehatan Kab.Lombok Utara Puskesmas Bayan 3031021
Dinas Kesehatan Kab.Lombok Utara Puskesmas Gangga 3031021
Dinas Kesehatan Kab.Lombok Utara Dinas Kesehatan Kab.Lombok Utara 4233489
Dinas Kesehatan Kab.Lombok Utara Puskesmas Penimbung 3022001
Dinas Kesehatan Kab.Lombok Barat Puskesmas Penimbung 3022001

Lampiran
Nomor : B/1511/M.SM.01.00/2022
Tanggal : 22 July 2022
Jabatan
Pembaya
Penandatangan SK ran
Nama (APBN/
PENYULUH KESEHATAN MASYARAKAKepala Dinas Kesehatan APBD

ANALIS KESEHATAN Kepala Dinas Kesehatan APBD
BIDAN Kepala Dinas Kesehatan APBD
BIDAN Kepala Puskesmas Nipah APBD
APOTEKER Kepala Dinas Kesehatan APBD
APOTEKER Kepala Puskesmas Pemenang APBD
DOKTER UMUM Kepala Dinas Kesehatan APBD
PENGEMUDI AMBULANS Kepala Dinas Kesehatan APBD
PERAWAT Kepala Dinas Kesehatan APBD
PETUGAS LOKET PUSKESMAS Kepala Dinas Kesehatan APBD
NUTRISIONIS Kepala Dinas Kesehatan APBD
TERAPIS GIGI DAN MULUT Kepala Puskesmas APBD
ANALIS KESEHATAN Kepala Puskesmas APBD
PERAWAT Kepala Puskesmas APBD
BIDAN Kepala Puskesmas APBD
JURU MASAK Kepala Puskesmas APBD
CLEANING SERVIS Kepala Puskesmas APBD
ADMINISTRASI UMUM Kepala Puskesmas APBD
M.SM.01.00/2022
Unit Kerja Penempatan

Jabatan Penandatangan S Pembayara
No NAMA NIK Nomor SK
1 Retno Widiastuti 3401094207960002 HK.01.07/MENKES/4623/2021

3401094207960002 HK.01.07/MENKES/632/2018
Setiap baris WAJIB untuk dipersiapkan dokumen SK Pengangkatan yang paling rendah oleh pimpinan unit kerja
Setiap baris dipersiapkan dokumen Bukti Pembayaran honorarium dengan mekanisme pembayaran langsung yang berasal dari APBN
RIWAYAT KONTRAK KERJA TENAGA NON ASN DAN EKS-TH
Tanggal
Awal
Kerja lnstansi Penempatan
(dd-mm-
yyyy)
4/26/2021 4/1/2021 3/31/2023 Dinas Kesehatan Kab.Lombok Utara
11/12/2018 12/1/2018 11/30/2020 Dinas Kesehatan Kabupaten Kota Tual
rasal dari APBN

Lampiran
Nomor
Tanggal
ASN DAN EKS-THK-II
Jabatan

Kode Nama
Puskesmas Nipah 4171024 TENAGA KESEHATAN LINGKUNGAN

Puskesmas Kaimear 4171024 TENAGA KESEHATAN LINGKUNGAN
: B/1511/M.SM.01.00/2022
: 22 July 2022
Pembayar
Penandatangan SK an
(APBN/
Kemenkes APBN
Kemenkes APBN
Unit Kerja Penempatan Jabatan
Penandatangan S Pembayara
No NAMA NIK Nomor SK
1 Eka Wahyuningsih 5208014204860001 HK.01.07/MENKES/4846/2021

5208014204860001 814/15.1/01/DIKES/2021
5208014204860001 814/56.2/01/DIKES/2020
5208014204860001 814/2.1/01/DIKES/2019
5208014204860001 814/01/DIKES/2018/01.C
5208014204860001 814/32.E/01/DIKES/2017
5208014204860001 814/742.3/01/DIKES/2016
5208014204860001 193/01/DIKES/2015
5208014204860001 KP.01.02.1.2.6666
5208014204860001
KP.01.02.1.2.8368
5208014204860001
KP.01.02.1.2.5806
5208014204860001 250/01/DIKES/2011
RIWAYAT KONTRAK KERJA TENAGA NON ASN DAN EKS-THK-II
Tanggal
Awal
(dd-mm-
yyyy)

rasal dari APBN

Lampiran
Nomor
Tanggal
ON ASN DAN EKS-THK-II
Jabatan

Kode Nama
Puskesmas Nipah 4213178 PERAWAT

Puskesmas Pemenang 4213178 PERAWAT
4213178 PERAWAT
Puskesmas Pemenang
4213178 PERAWAT
Puskesmas Pemenang
: B/1511/M.SM.01.00/2022
: 22 July 2022
Pembayar
Penandatangan SK an
(APBN/
Kemenkes APBN
Kepala Dinas Kesehatan APBD
Kepala Dinas Kesehatan
a.n.MENKES RI/Kepala Biro APBD
Kepegawaian APBN
a.n.MENKES RI/Kepala Biro
Kepegawaian APBN
a.n.MENKES RI/Kepala Biro
Kepegawaian APBN
R
No NIK Nomor SK
1 Baiq Amanda Soleha 5208054808990002 503.1/SPK/DINKES/III/2022

2 HUSNUL HADI 5208050511970003 503.1/SPK/DINKES/III/2022
3 NURUL HIDAYAH 5208014809960004 503.1/SPK/DINKES/III/2023
4 ILHAM
5 NOVITAEKA
HARDIANTI
ATMAYUDA 5208055111990001
5208012910180011 503.1/SPK/DINKES/III/2023
114.a/01/PKM.N/IV/2022
6 AL PACHRUR ROZY 5208012106980002 114.a/01/PKM.N/IV/2022
7 HUMAIYASTRI 5208016408010003 114.a/01/PKM.N/IV/2022
8 ISLAWATI 5208057112980000 114.a/01/PKM.N/IV/2022
Tanggal
Awal
(dd-mm-
yyyy)
3/1/2022
4/1/2022 3/1/2022
4/1/2022 12/31/2022 Dinas Kesehatan Kab.Lombok Utara
31/12/2022
Lampiran
Nomor
Tanggal
DAN EKS-THK-II
Jabatan

Kode Nama
Puskesmas Nipah 3003001 BIDAN

Puskesmas Nipah 4236282 TUKANG KEBUN ATAU KEBERSIHAN
Puskesmas Nipah 3002002 ASISTEN APOTEKER
Puskesmas Nipah 4206222 CLEANING SERVIS
4198754 ADMINISTRASI UMUM
Puskesmas Nipah 3003001 BIDAN
: B/1511/M.SM.01.00/2022
: 22 July 2022
Pembaya
(APBN/

Dinas Kesehatan
Kepala Puskesmas APBD
Unit Kerja Penempatan Jabatan
Penandatangan S Pembayara
RIWAYAT KON
Nama Instansi : UPT BLUD PKM NIPAH
Tanggal SK
No NIK Nomor SK
(dd-mm-yyyy)
1 Raning Indah 5271036101890001 814/56.2/01/DIKES/2020 1/2/2020

5271036101890001 814/2.1/01/DIKES/2019 1/2/2019
5271036101890001 814/01.c/01/DIKES/2018 1/2/2018
5271036101890001 814/32.E/01/DIKES/2017 1/9/2017
5271036101890001 814/742.3/01/DIKES/2016 5/2/2016
2 Desi Wulandari 5208054612910001 193/01/DIKES/2015 1/5/2015
5208054612910001 266/01/DIKES/2014 2/3/2014
5208054612910001 434/01/DIKES/2013 2/11/2013
5208054612910001 292/01/DIKES/2012 2/6/2012
3 WIWI SUMBAWATI 5208055406910005 814/2.1/01/DIKES/2019 1/2/2019
5208055406910005 814/01.c/01/DIKES/2018 1/2/2018
5208055406910005 814/1503.a/01/DIKES/2017 10/2/2017
4 Ita Qaulina 3212156102890004 814/01.c/01/DIKES/2018 1/2/2018
3212156102890004 814/32.E/01/DIKES/2017 1/9/2017
5 Warni 5208057112880135 431/01/DIKES/2013 2/11/2013
5208057112880135 800/397/IV/2008 4/26/2008
untuk lnstansi Pusat dan APBD untuk lnstansi Daerah, dan bukan melalui mekanisme pengadaan barang dan jasa, baik individu
Keterangan pengisian:
1 Nomor urut
2 NIK tenaga non ASN atau eks THK2
3 Nomor SK jabatan pad a riwayat tersebut
4 Tanggal SK jabatan pada riwayat tersebut
5 Tanggal awal kerja jabatan pada riwayat tersebut
6 Tanggal akhir kerja jabatan pada riwayat tersebut
7 lnstansi penempatan pada riwayat tersebut
8 Unit kerja penempatan pada riwayat tersebut
9 Kode jabatan pada riwayat tersebut
10 Nama jabatan pada riwayat tersebut
11 Penanda tangan SK jabatan pada riwayat terse but
12 Pembayaran hanya dengan mekanisme pembayaran langsung yang berasal dari APBN untuk lnstansi Pusat dan APBD untuk lnstansi Daerah, dan bukan melalui mekanism
Tanggal
Awal
Tanggal Akhir Kerja
Kerja lnstansi Penempatan Unit Kerja Penempatan
(dd-mm-yyyy)
(dd-mm-
yyyy)
1/1/2020 4/30/2020 Dinas Kesehatan Kab.Lombok Utara Puskesmas Nipah
1/1/2018 10/31/2018 Dinas Kesehatan Kab.Lombok Utara Puskesmas Pemenang
rah, dan bukan melalui mekanisme pengadaan barang dan jasa, baik individu maupun pihak ketiga
Lampiran
Nomor : B/1511/M.SM.01.00/2022
Tanggal : 22 July 2022
Jabatan
Pembaya
Kode Nama (APBN/
3003001 BIDAN Kepala Dinas Kesehatan APBD

4213178 PERAWAT Kepala Dinas Kesehatan APBD
4213178 PERAWAT Kepala Dinas Kesehatan APBD

Format Pengisian Lampiran II PKM Nipah

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Nama Instansi : UPT BLUD PKM Nipah

1 Ni.Nyoman Astuti Ariastini 5208014404810003

04.1/SPK/DIKES/I/DIKES/2022 1/3/2022 1/1/2022 12/31/2022

018/01/PKM.N/I/2021 1/2/2021 1/2/2021 31/12/2021

lnstansi Penempatan Unit Kerja Penempatan

Dinas Kesehatan Kab.Lombok Utara Puskesmas Nipah 4198499

Dinas Kesehatan Kab.Lombok Utara Puskesmas Nipah 4213178

Dinas Kesehatan Kab.Lombok Utara Puskesmas Nipah 4213178

PENYULUH KESEHATAN MASYARAKAKepala Dinas Kesehatan APBD

Unit Kerja Penempatan

No NAMA NIK Nomor SK

1 Retno Widiastuti 3401094207960002 HK.01.07/MENKES/4623/2021

rasal dari APBN

ASN DAN EKS-THK-II

Unit Kerja Penempatan

Puskesmas Nipah 4171024 TENAGA KESEHATAN LINGKUNGAN

No NAMA NIK Nomor SK

1 Eka Wahyuningsih 5208014204860001 HK.01.07/MENKES/4846/2021

11/30/2012 1/1/2013 12/31/2013 Dinas Kesehatan Kab.Lombok Utara

12/27/2011 1/1/2012 12/31/2012 Dinas Kesehatan Kab.Lombok Utara

rasal dari APBN

ON ASN DAN EKS-THK-II

Unit Kerja Penempatan

Puskesmas Nipah 4213178 PERAWAT

1 Baiq Amanda Soleha 5208054808990002 503.1/SPK/DINKES/III/2022

Unit Kerja Penempatan

Puskesmas Nipah 3003001 BIDAN

Kepala Dinas Kesehatan APBD

1 Raning Indah 5271036101890001 814/56.2/01/DIKES/2020 1/2/2020

3003001 BIDAN Kepala Dinas Kesehatan APBD

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