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FORMULIR 5 LAMPIRAN PERATURAN MENTERI KESEHATAN NOMOR : 143/MENKES/PER/VII/77

TANGGAL : 1 JULI 1977

HASIL PENGUJIAN KESEHATANNO / DPT / 2012 / /812

D!"#$ P#%&'() T#$*#%+)$) /T#,- P#%&'() /T#,- K.'*'* P#%&'() K#*#.,",% P#&,,) N#$) S)) +) T#-),.,%

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2012 D,% #$#%+,," ,., ,%& +)#$)!*, :

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#$' +)',%& *#"#,. *##*,) #%&,",% / #$,,",% ,",' +)",! '%"'! *#-#%",$,# T)+,! -#-#%'.) *,$," '%"'! -#%(,,%!,% "'&,* *#,&,) P#&,,) N#$) S)) ,",' +)",!

H,*) #%&'(),% !#*#.,",% )%) +)#$)!,% ,",* %,-, DPT / TPK P#$,"'$,% P#%&'(),% K#*#.,",% N-$ 2 T,.'% 1977

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S,)%,% H,*) K#'"'*,% P#%&'()K#*#.,",% +)!)$)- !#,+, : T)- P#%&'() K#*#.,",%#$*,%&!'",%3A$*)

dr.Yandri Saputra, Sp.M

NIP19590119 198802 1 001





2/4

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N , - , : F)"$),%)< SP) N,-, K#) : IB)"N I P : 19821007 200903 2 011 K,$#& :T#-,"/T& ,.)$ : P',' K)(,%&< 7 O!"#$ 1982 G%&,% $',%& : III/,P#!#$(,,% : =,% P#&,,) N#$) S))A,-," : K-#! A* K#$)",%& "#,. +)#$)!*, +#%&,% "#)") ,",* #$-)%",,%

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#$' +)',%& *#"#,. *##*,) #%&,",% / #$,,",% ,",' +)",! '%"'! *#-#%",$,# T)+,! -#-#%'.) *,$," '%"'! -#%(,,%!,% "'&,* *#,&,) P#&,,) N#$) S)) ,",' +)",!

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NIP19591019 198802 1 001




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A,-," : JG'%'%& D,#! G&S'!, J,+) N104 "#,. +)#$)!*, +#%&,% "#)") ,",* #$-)%",,%K#,, >,+,% P#,!*,%, P#%''.,% +,% K#",.,%,% P,%&,% K,',"#%I%.) +#%&,% S'$," N: 701/>P2KP/II/?/2011

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#$' +)',%& *#"#,. *##*,) #%&,",% / #$,,",% ,",' +)",! '%"'! *#-#%",$,# T)+,! -#-#%'.) *,$," '%"'! -#%(,,%!,% "'&,* *#,&,) P#&,,) N#$) S)) ,",' +)",!

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NIP19591019 198802 1 001




D!"#$ P#%&'() T#$*#%+)$) /T#,- P#%&'() /T#,- K.'*'* P#%&'() K#*#.,",% P#&,,) N#$) S)) +) T#-),.,%

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N , - , : K,$+)%,< SP N,-, K#) : I%,N I P : 19740728 200903 1 002 K,$#& :T#-,"/T& ,.)$ : P,+,%&< 28 J') 1974 G%&,% $',%& : III/,P#!#$(,,% : =,% P#&,,) N#$) S))A,-," : JS,$%, >'-) T#-),.,% "#,. +)#$)!*, +#%&,% "#)") ,",* #$-)%",,%


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#$' +)',%& *#"#,. *##*,) #%&,",% / #$,,",% ,",' +)",! '%"'! *#-#%",$,# T)+,! -#-#%'.) *,$," '%"'! -#%(,,%!,% "'&,* *#,&,) P#&,,) N#$) S)) ,",' +)",!

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NIP19591019 198802 1 001

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