LOGBOOK Kegiatan Pre Dietetics Internship Rotasi Community Dietetics Program Studi Ilmu Gizi Fakultas Kedokteran Universitas Brawijaya 2015
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LOGBOOK Kegiatan Pre Dietetics Internship Rotasi Community Dietetics
Program Studi Ilmu Gizi
Fakultas Kedokteran Universitas Brawijaya
2015
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
1
LOGBOOK
KEGIATAN PRE DIETETICS INTERNSHIP – ROTASI COMMUNITY DIETETICS
PROGRAM STUDI ILMU GIZI FAKULTAS KEDOKTERAN UNIVERSITAS BRAWIJAYA
SEMESTER GANJIL TAHUN AJARAN 2015/2016
NAMA : _______________________________
NIM : _______________________________
PUSKESMAS : _______________________________
ALAMAT : _______________________________
NO TELP : _______________________________
Malang,
___________________________
(Nama mahasiswa & tanda tangan)
Jl. Veteran Malang – 65145
Telp. (0341) 567192, 569117 Pswt. 132, 133; Fax. (0341) 564755
Website: http://gizi.fk.ub.ac.id, Email: [email protected]
Foto
berwarna
3 x 4 cm
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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FORM PERSETUJUAN KEGIATAN PRE DI ROTASI COMMUNITY
No Kegiatan
Persetujuan
Supervisor Persetujuan CI
Persetujuan
Perceptor
Tgl TTD Tgl TTD Tgl TTD
1. Persetujuan
pengambilan data
2. Persetujuan penentuan
masalah dan diagnosa
gizi komunitas
3. Persetujuan
pelaksanaan intervensi
4. Persetujuan
pelaksanaan monitoring
& evaluasi
5. Persetujuan
dilaksanakan presentasi
6. Persetujuan laporan
akhir
Malang,
Supervisor,
____________________
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN COMMUNITY INSTRUCTURE
Tanggal Materi Konsultasi Hasil Konsultasi Paraf CI
Malang, …………………………..
Community Instructure,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN COMMUNITY INSTRUCTURE
Tanggal Materi Konsultasi Hasil Konsultasi Paraf CI
Malang, …………………………..
Community Instructure,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN PERCEPTOR
Tanggal Materi Konsultasi Hasil Konsultasi Paraf
Perceptor
Malang, …………………………..
Perceptor,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN PERCEPTOR
Tanggal Materi Konsultasi Hasil Konsultasi Paraf
Perceptor
Malang, …………………………..
Perceptor,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN SUPERVISOR
Tanggal Materi Konsultasi Hasil Konsultasi Paraf Spv
Malang, …………………………..
Supervisor,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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LEMBAR KONSULTASI DENGAN SUPERVISOR
Tanggal Materi Konsultasi Hasil Konsultasi Paraf Spv
Malang, …………………………..
Supervisor,
____________________
(Nama & TTD)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
11
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
13
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
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CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
16
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
17
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
18
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
19
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
Pedoman Log Book Pre-DI Community Edisi Semester Ganjil 2015/2016
20
CATATAN KEGIATAN HARIAN PESERTA
Rotasi :
Hari/tanggal :
JAM URAIAN KEGIATAN KET
Catatan:
(Perceptor)
(Community Instructure)
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