KEMENTERIAN RISET, TEKNOLOGI DAN PENDIDIKAN TINGGI

UNIVERSITAS BRAWIJAYA FAKULTAS KEDOKTERAN

SURAT KETERANGAN

JURUSAN KEPERAWATAN
Jalan Veteran Malang 65145, Jawa Timur - Indonesia

Telp. (0341) 551611 Pes. 213.214; 569117, 567192 Pes 125 Fax. (62) (0341) 564755

Departemen

: ...............................................................................................(Diisi sesuai departemen)

Kelompok

: ........................................................................(Diisi dengan huruf romawi : I, II, III, dst)

Program

:. ..................................................................................................(Diisi PSIK A / PSIK B)

Angkatan

: ......................................................................(Diisi tahun angkatan mahasiswa masuk)

Tahun Akademik

: ...............................................................................(Diisi ganjil-genap tahun akademik)

e-mail : keperawatan.fk@ub.ac.id h t t p : / / w w w . f k . u b . a c . i d

NO

NAMA

Institusi

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Jurusan Keperawatan
Fakultas Kedokteran
Universitas Brawijaya

Menyatakan bahwa mahasiswa tersebut diatas telah menempuh Praktik Klinik Profesi Ners dengan :
Tempat

: ........................................................................................................................................

Tanggal

: .............................................................. s/d ...................................................................

Demikian surat keterangan ini dibuat untuk digunakan sebagaimana mestinya.

Dikeluarkan di : M a l a n g
Mengetahui

Pada tanggal

---------------------------------------------------------Pembimbing Institusi

Pembimbing Lahan,

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NIP.

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NIP.

Ketua Jurusan Keperawatan FK Universitas Brawijaya

Dr. Ahsan, S.Kp, M.Kes

NIP. 196408141984011001