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FORMULIR SASARAN KERJAPEGAWAI NEGERI SIPIL*

NO I. PEJABAT PENILAI NO II. PEGAWAI NEGERI SIPIL YANG DINILAI1 Nama JUNAEDI, SKM M Kes 1 Nama Dra. NURUL HIDAYATI2 NIP 19640601 19880 1 012 2 NIP 196!0614 199 0 2 004

Pa"#$a%&'().R*a"# PEM+INA T$ I & I - Pa"#$a%&'().R*a"# PEM+INA & I a4 Ja-a%a" KEPALA +ADAN KK+ PP a" PA 4 Ja-a%a" KEPAL UPT +ADAN KK+ PP a" PA/ U" % Ker a +ADAN KK+ PP a" PA / U" % Ker a +ADAN KK+ PP a" PA

NO III. KEGIATAN TUGAS JABATAN AKTARGET

KUANT/OUTPUT KUAL/MUTU WAKTU BIAYA

1 Me" *s*" re"3a"a $er a %a *"a" UPT +KK+ PP a" PA Ke3. Sa5*ra" 1 La5(ra" 100 1 +*)a" 2 Me"#$((r " r a" me"#esa $a" re"3a"a $er a PK+ T 2014 / La5(ra" 100 1 +*)a"

Me)a$sa"a$a" S(s a) sas PK 201/ 1 La5(ra" 100 1 +*)a" 4 Me)a$sa"a$a" Pe" a%aa" Ke)*ar#a 201/ 18 D($*me" 100 4 +*)a" / Me)a$sa"a$a" E7a)*as as ) Pe" a%aa" 1 D($*me" 100 1 +*)a" 6 Me)a$sa"a$a" sarase a" as ) 5e" a%aa" $e)*ar#a 1 La5(ra" 100 1 +*)a" ! Me)a$sa"a$a" Ra$(r Pr(#ram K+ T$ Ke3ama%a" 12 La5(ra" 100 12 +*)a" 8 Me)a$sa"a$a" 5em- "aa" 5e#a a me)a)* s%a mee% "# 12 La5(ra" 100 12 +*)a" 9 Me"# $*% ra5a% 5 m5 "a" +a a" K+ Ka-*5a%e" 12 La5(ra" 100 12 +*)a" 10 Me"# $*% ra5a% e"#a" D "as I"s%a"s %er%$a % 10 La5(ra" 100 12 +*)a" 11 Me"e) % a" me"a" a%a"# s*ra% "as 16 La5(ra" 100 12 +*)a" 12 Me)a$sa"a$a" $e# a%a" 5e" e aa" a)a% $("%rase5s 12 La5(ra" 100 12 +*)a" 1 Me"e) % a" me"a" a%a"#a" $e-*%* a" a)a% $("%rase5s 12 La5(ra" 100 12 +*)a" 14 Me)a$sa"a$a" $er a sama $em %raa" e"#a" LS:M a)am 5e)a$s 5e)a a"a" K+ / La5(ra" 100 12 +*)a" 1/ Me" e)e"##ara$a" 5r(m(s , a 7($as , KIE a" K("se) "# 20 A$se5%(r 100 12 +*)a" 16 Me)a$sa"a$a" 5e" "#$a%a" 3a5a a" $eser%aa" K+ Pr a 1/ A$se5%(r 100 12 +*)a" 1! Me)a$sa"a$a" $e# a%a" 5e)a a"a" $("%rase5s -a# 5eser%a K+ +ar* 18 4 La5(ra" 100 12 +*)a" 18 Me)a$sa"a$a" 5em- "aa" ase5%(r K+ a$% 9899 La5(ra" 100 12 +*)a" 19 Me)a$sa"a$a" 5e"##era$a" a)am *5a a 5e"*r*"a" PUS U" mee "ee 0./ La5(ra" 100 12 +*)a" 20 Me)a$sa"a$a" 5em- "aa" Ke)(m5($ PIK Rema a 1 La5(ra" 100 12 +*)a" 21 Me)a$sa"a$a" $e# a%a" KIE KRR *"%*$ me"*r*"$a" PUS ; 20 T 0./ La5(ra" 100 12 +*)a" 22 Me)a$sa"a$a" 5em- "aa" Ke)(m5($ +K+ 2/ La5(ra" 100 12 +*)a" 2 Me)a$sa"a$a" 5em- "aa" $e)(m5($ +KR 1! La5(ra" 100 12 +*)a" 24 Me)a$sa"a$a" 5em- "aa" $e)(m5($ +KL 1! La5(ra" 100 12 +*)a" 2/ Me)a$sa"a$a" 5em- "aa" $e)(m5($ UPPKS !! La5(ra" 100 12 +*)a" 26 Me)a$sa"a$a" 5em- "aa" $e)(m5($ IMP < PPK+D = 1! La5(ra" 100 12 +*)a" 2! Me)a$sa"a$a" 5e"#e)()aa" a%a m $r( 5r(#ram K+ 12 La5(ra" 100 12 +*)a" 28 Mem-*a% )a5(ra" as ) $e# a%a" 5r(#ram KK+ % "#$a% Ke3ama%a" 12 La5(ra" 100 12 +*)a" 29 Me" a%a sara"a 5rasara"a a" 5e"#e)()a 5r(#ram KK+ me)a)* K&: 4 La5(ra" 100 12 +*)a"



+*)a"

Wonosobo, 08 Januari 2015Pejabat Penilai, Pegawai Negeri Sipil Yang Dinilai

JUNAEDI, SKM M Kes Dra. NURUL HIDAYATI196 0601 19880! 1 012 196"061 199!0! 2 00



I. ATASAN PEJABAT PENILAINama M. >UHRI, S.S(s, M.SNIP 19610612198/0 1019Pa"#$a%&'().R*a"# PEM+INA UTAMA MUDA & <I &3=Ja-a%a" KEPALAU" % Ker a +ADAN KK+ PP a" PA

KET :

1. U"%*$ K()(m AK <A"#$a Kre %= $a)a* % a$ a a s e"#a"

2. U"%*$ K()(m +IAYA <A"#$a Kre %= $a)a* % a$ a a s e"#a"

'- $em* a" %e$a"Enter < Pe% $ S%r 5 E"%er =

'- $em* a" %e$a"Enter < Pe% $ S%r 5 E"%er =



PENILAIAN CAPAIAN SASARAN KERJAPEGAWAI NEGERI SIPIL*

Jang#a Wa#tu Penilaian 02 Januari s$%$ !1 Dese&ber 201

NO I. Kegiata T!gas Ja"ata AKTARGET

AKR

'uant( )utput 'ual(*utu Wa#tu +ia a 'uant( )utput 'ual(*utu Wa## $ % & ' ( ) * + #

1 1 La5(ra" 100 1 +*)a" 1 La5(ra"

2 / La5(ra" 100 1 +*)a" / La5(ra" 8

Me)a$sa"a$a" S(s a) sas PK 201/ 1 La5(ra" 100 1 +*)a" 1 La5(ra"

Me)a$sa"a$a" Pe" a%aa" Ke)*ar#a 201/ 18 D($*me" 100 4 +*)a" 18 D($*me"

4 Me)a$sa"a$a" E7a)*as as ) Pe" a%aa" 1 D($*me" 100 1 +*)a" 1 D($*me"

/ Me)a$sa"a$a" sarase a" as ) 5e" a%aa" $e)*ar#a 1 La5(ra" 100 1 +*)a" 1 La5(ra"

6 Me)a$sa"a$a" Ra$(r Pr(#ram K+ T$ Ke3ama%a" 12 La5(ra" 100 12 +*)a" 12 La5(ra"

! Me)a$sa"a$a" 5em- "aa" 5e#a a me)a)* s%a mee% "# 12 La5(ra" 100 12 +*)a" 12 La5(ra"

8 Me"# $*% ra5a% 5 m5 "a" +a a" K+ Ka-*5a%e" 12 La5(ra" 100 12 +*)a" 12 La5(ra"

9 Me"# $*% ra5a% e"#a" D "as I"s%a"s %er%$a % 10 La5(ra" 100 12 +*)a" 10 La

10 Me"e) % a" me"a" a%a"# s*ra% "as 16 La5(ra" 100 12 +*)a" 16 La5(ra"

11 Me)a$sa"a$a" $e# a%a" 5e" e aa" a)a% $("%rase5s 12 La5(ra" 100 12 +*)a" 12 La5(ra"

12 Me"e) % a" me"a" a%a"#a" $e-*%* a" a)a% $("%rase5s 12 La5(ra" 100 12 +*)a" 12 La5(r

1 / La5(ra" 100 12 +*)a" / 0

14 20 A$se5%(r 100 12 +*)a" A$se5%(r

1/ Me)a$sa"a$a" 5e" "#$a%a" 3a5a a" $eser%aa" K+ Pr a 1/ A$se5%(r 100 12 +*)a" A$se5%(r

16 18 4 La5(ra" 100 12 +*)a" La5(ra"1! Me)a$sa"a$a" 5em- "aa" ase5%(r K+ a$% 9899 La5(ra" 100 12 +*)a" La5(ra"

18 0./ La5(ra" 100 12 +*)a" La5(ra"

19 Me)a$sa"a$a" 5em- "aa" Ke)(m5($ PIK Rema a 1 La5(ra" 100 12 +*)a" La5(ra"

20 0./ La5(ra" 100 12 +*)a" La5(ra"

21 Me)a$sa"a$a" 5em- "aa" Ke)(m5($ +K+ 2/ La5(ra" 100 12 +*)a" La5(ra"

22 Me)a$sa"a$a" 5em- "aa" $e)(m5($ +KR 1! La5(ra" 100 12 +*)a" La5(ra"

2 Me)a$sa"a$a" 5em- "aa" $e)(m5($ +KL 1! La5(ra" 100 12 +*)a" La5(ra"

24 Me)a$sa"a$a" 5em- "aa" $e)(m5($ UPPKS !! La5(ra" 100 12 +*)a" La5(ra"

2/ Me)a$sa"a$a" 5em- "aa" $e)(m5($ IMP < PPK+D = 1! La5(ra" 100 12 +*)a" La5(ra"

Me" *s*" re"3a"a $er a %a *"a" UPT +KK+ PP a" PAKe3. Sa5*ra"

Me"#$((r " r a" me"#esa $a" re"3a"a $er a PK+ T

2014

Me)a$sa"a$a" $er a sama $em %raa" e"#a" LS:Ma)am 5e)a$s 5e)a a"a" K+e" ee"##ara a" 5r(m(s , a 7( as , a"

e a sa"a a" e# a a" 5ea a"a" (" rase5s a#eser%a K+ +ar*

e a sa"a a" 5e"##era a" a am *5a a 5e"*r*"a"PUS U" mee "ee

ea sa"a a" e#a a" *" * me"*r*" a"PUS ; 20 T



26 Me)a$sa"a$a" 5e"#e)()aa" a%a m $r( 5r(#ram K+ 12 La5(ra" 100 12 +*)a" La5(ra"

2! 12 La5(ra" 100 12 +*)a" La5(ra"

28 4 La5(ra" 100 12 +*)a" La5(ra"

1 t!gas ta "a0a 1t!gas ta "a0a 1

2 2reati3itas1

2reati3itas1

Ni4ai -a5aia SKP

Mem-*a% )a5(ra" as ) $e# a%a" 5r(#ram KK+ % "#$a%Ke3ama%a"

Me" a%a sara"a 5rasara"a a" 5e"#e)()a 5r(#ram KK+me)a)* K&:

II. TUGAS TAMBAHAN DANKREATI6ITAS/UNSUR PENUNJANG 7



8ORM PENILAIAN PERILAKU KERJA PNS

Peri4a2! Ker9a

#. Orie tasi Pe4a:a a 80 +ai#

$. I tegritas "9 +ai#

%. K; it e "9 +ai#

&. Disi54i 80 +ai#

'. Ker9asa a "9 +ai#

(. Ke5e i 5i a 80 +ai# -- D. .S. / NY N ' Y N3 P4J + S '

KET 77 ntu# J ( J Sila #an isi ( #eti# Nilai an a pa%a #olo& ang berwarna HIJAU7 ntu# Pejabat Stru#tural sila #an isi ( #eti# Nilai pa%a se&ua #olo& : HIJAU < KUNING ;



8$ REKOMENDASI

P4*4 .N / ' +$ W)N)S)+)

1$ Y N3 D.N. .a$ N a & a

b$ N . P

9$ D.+ N33 , !1 D4S 201<$ Pang#at(3olongan ruang

P4J + P4N. . %$ Jabatan(Pe#erjaan

e$ nit )rganisasi

JUNAEDI, SKM M Kes2$ P4J + P4N. .

N.P 196 0601 19880! 1 012 a$ N a & a

10$ D. 4 .* N33 , 02 J N 2015b$ N . P

P43 W . N434 . S.P. Y N3 D.N. ., <$ Pang#at(3olongan ruang

%$ Jabatan(Pe#erjaan

Dra. NURUL HIDAYATIe$ nit )rganisasi

N.P 196"061 199!0! 2 00!$ S N P4J + P4N. .

11$D. 4 .* N33 , 0" J N 2015a$ N a & a

S N P4J + P4N. . b$ N . P

PENILAIAPEGA



<$ Pang#at(3olongan ruang

M. =UHRI, S.S;s, M.Si%$ Jabatan(Pe#erjaan

N.P 1961061219850!1019 e$ nit )rganisasi

$ NS Y N3 D.N. . Ju&la 6$ N33 P N P4J + P4N. .

a$ Sasaran '

erja Pegawai :S'P; 69$!! = 60> 1$60

1$ )rientasi Pela anan 80 +ai#

2$ .ntegritas "9 +ai#

!$ 'o&it&en "9 +ai#

b$ $ Disiplin 80 +ai#

5$ 'erjasa&a "9 +ai#

6$ 'epe&i&pinan 80 +ai#

Ju&la ""

Nilai rata7rata "9$50 +ai#

Nilai Perila#u 'erja "9$50 = 0 > !1$80"$ '4P S N S N P4J + P4

N. . P 4S S. '4 J)%.&

'4+4 N

-!2!5 1

5$

Perila#u'erja

'4+4 N D . P43 W . N434 . S.P. Y N3D.N. . : P +. D ;



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J N3' W ' P4N. . N J N . s$%$ !1 D4S4*+4 201

Dra$ N /.D Y .

196"061 199!0! 2 00

P4*+.N ( .? a

'4P P + D N ''+ PP %an P

+ D N ''+ PP %an P

J N 4D., S'* * 'es

196 0601 19880! 1 012

196 0601 19880! 1 012

P4*+.N # . ( .? b

'4P + D N ''+ PP %an P

*$ @ / ., S$Sos, *$Si

1961061219850!1019

PRESTASI KERJAAI NEGERI SIPIL



P4*+.N * * D ( :.?(<;

'4P

+ D N ''+ PP %an P

S '4+4 N

anggal,

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anggal,



8$ REKOMENDASI

P4*4 .N / ' +$ W)N)S)+)

1$ Y N3 D.N. .

a$ N a & a

b$ N . P

9$ D.+ N33 , !1 D4S 201 <$ Pang#at(3olongan ruang

P4J + P4N. . %$ Jabatan(Pe#erjaan

e$ nit )rganisasi

JUNAEDI, SKM M Kes2$ P4J + P4N. .

N.P 196 0601 19880! 1 012 a$ N a & a

10$ D. 4 .* N33 , 02 J N 2015b$ N . P

P43 W . N434 . S.P. Y N3 D.N. ., <$ Pang#at(3olongan ruang

%$ Jabatan(Pe#erjaan

Dra. NURUL HIDAYATIe$ nit )rganisasi

N.P 196"061 199!0! 2 00!$ S N P4J + P4N. .

11$D. 4 .* N33 , 0" J N 2015a$ N a & a

S N P4J + P4N. . b$ N . P

<$ Pang#at(3olongan ruang

PENILAIAPEGA



M. =UHRI, S.S;s, M.Si%$ Jabatan(Pe#erjaan

N.P 1961061219850!1019 e$ nit )rganisasi

$ NS Y N3 D.N. . Ju&la 6$ N33 P N P4J + P4N. .

a$ Sasaran '

erja Pegawai :S'P; 69$!! = 60> 1$60

1$ )rientasi Pela anan 80 +ai#

2$ .ntegritas "9 +ai#

!$ 'o&it&en "9 +ai#

b$ $ Disiplin 80 +ai#

5$ 'erjasa&a "9 +ai#

6$ 'epe&i&pinan 7 7

Ju&la !9"

Nilai rata7rata "9$ 0 +ai#

Nilai Perila#u 'erja "9$ 0 = 0 > !1$"6"$ '4P S N S N P4J + P4

N. . P 4S S. '4 J)%.%( '4+4 N

-!2!5 1

5$

Perila#u'erja

'4+4 N D . P43 W . N434 . S.P. Y N3D.N. . : P +. D ;



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J N3' W ' P4N. . N02 J N . s$%$ !1 D4S4*+4 201

Dra$ N /.D Y .196"061 199!0! 2 00

P4*+.N ( .? a

'4P P + D N ''+ PP %an P

+ D N ''+ PP %an P

J N 4D., S'* * 'es

196 0601 19880! 1 012

196 0601 19880! 1 012

P4*+.N # . ( .? b

'4P + D N ''+ PP %an P

*$ @ / ., S$Sos, *$Si

1961061219850!1019

P4*+.N * * D ( :.?(<;

PRESTASI KERJAAI NEGERI SIPIL



'4P

+ D N ''+ PP %an P

S '4+4 N

anggal,

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anggal,



PENILAIAN CAPAIAN SASARAN KERJAPEGAWAI NEGERI SIPIL*

Jang#a Wa#tu Penilaian 02 Januari s$%$ !1 Dese&ber 201

NO I. Kegiata T!gas Ja"ata AKTARGET

AKREAL

'uant( )utput 'ual(*utu Wa#tu +ia a 'uant( )utput 'ual(*utu Wa#tu# $ % & ' ( ) * + #

1 1 La5(ra" 100 1 +*)a" 124 La5(ra" 80

2 / La5(ra" 100 1 +*)a" 1042 La5(ra" 80

Me)a$sa"a$a" Pe" a%aa" Ke)*ar#a 201/ 18 D($*me" 100 4 +*)a" 904 D($*me" 80

4 Me)a$sa"a$a" E7a)*as as ) Pe" a%aa" 1 D($*me" 100 1 +*)a" 6 D($*me" 80

/ Me)a$sa"a$a" sarase a" as ) 5e" a%aa" $e)*ar#a 1 La5(ra" 100 1 +*)a" !8 La5(ra" 80

6 Me)a$sa"a$a" Ra$(r Pr(#ram K+ T$ Ke3ama%a" 12 La5(ra" 100 12 +*)a" / La5(ra" 80

! Me)a$sa"a$a" 5em- "aa" 5e#a a me)a)* s%a mee% "# 12 La5(ra" 100 12 +*)a" 0 La5(ra"

8 Me"# $*% ra5a% 5 m5 "a" +a a" K+ Ka-*5a%e" 12 La5(ra" 100 12 +*)a" La5(ra"

9 Me"# $*% ra5a% e"#a" D "as I"s%a"s %er%$a % 10 La5(ra" 100 12 +*)a" La5(ra"

10 Me"e) % a" me"a" a%a"# s*ra% "as 16 La5(ra" 100 12 +*)a" La5(ra"

11 4 La5(ra" 100 12 +*)a" La5(ra"

1 t!gas ta "a0a 1

t!gas ta "a0a 1

2 2reati3itas1

2reati3itas1

Ni4ai -a5aia SKP

Me" *s*" re"3a"a $er a %a *"a" UPT +KK+ PP a" PAKe3. Sa5*ra"

Me"#$((r " r a" me"#esa $a" re"3a"a $er a PK+ T2014

Me" a%a sara"a 5rasara"a a" 5e"#e)()a 5r(#ram KK+me)a)* K&:

II. TUGAS TAMBAHAN DANKREATI6ITAS/UNSUR PENUNJANG 7



1 , IB<%ar#e% $*a%C0 1 0=

2 , IBERR:R<" )a 3a5a a" s$5 0=

> W ' , 100 <Rea) sas a$%*&%ar#e% a$%* 100=

,>+. Y , 100 <Rea) sas + a a&%ar#e% + a a 100=

' N . S , Rea) sas $*a"% %as&Tar#e% $*a"% %as 100

' . S Rea) sas M*%*&Tar#e% M*%* 100

W ' IB<FGa$%*C24 B8 E8=

+. Y IB<F- a aC24 '9 B9=

W-2 <<1,!6 %ar#e% a$%* rea) sas a$%*=&%ar#e% a$%*= 100

WA2 !6 <<<<1,!6 %ar#e% Ga$%* Rea) sas Ga$%*=&%ar#e% Ga$%*= 100= 1

+-2 B::1,"6C arget bia a7 ealisasi bia a;( arget bia a;C10+A2 !6 <<<<1,!6 %ar#e% - a a Rea) sas - a a=&%ar#e% - a a= 100= 100=

> SUM ?RE8@1/D#'1 B# B#$

form p2kpns

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