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8/18/2019 Copy of Form SKP-Final
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DATA SASARAN KERJA PEGAWAI
1 YANG DINILAI
a. Nama : HARI WIDAYATI, S.KEP
b. NIP : 19710726 199403 2 002c. Pa!"a#$G%&.R'a! : PENATA TINGKAT I$ III (
(. )aba#a : PERAWAT PENYELIA
*. +# K*-a : PK/ HA)I/ENA
2 PE)AAT PENILAI
a. Nama : DERAH/AN, SP.//
b. NIP : 1966009 199303 1 00
c. Pa!"a#$G%&.R'a! : PENATA TINGKAT I$ III (
(. )aba#a : KEPALA P+SKES/AS
*. +# K*-a : +PT.PK/ HA)I/ENA
3 ATASAN PE)AAT PENILAI
a. Nama : AH/AD RDHI, SK/./.KES
b. NIP : 196200 1903 1 00
c. Pa!"a#$G%&.R'a! : PE/INA TINGKAT I $ I b(. )aba#a : SEKERTARIS DINAS KESEHATAN LA/SEL
*. +# K*-a : DINAS KESEHATAN LA/P+NG SELATAN
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PENILAIAN PRESTASI KERJA
PEGAWAI NEGERI SIPIL
Jangka Waktu Penilaian2 Januari !" #$ Dee%&er 2'$(
Nama P*!a5a : )ARI WIDA*ATI+ S,KEP
NIP : 19710726 199403 2 002Pa!"a# G%&%!a R'a : PENATA TINGKAT I$ III (
)aba#a : PERAWAT PENYELIA
+# K*-a : PK/ HA)I/ENA
BADAN KEPEGAWAIAN NEGARA
TA)UN 2'$(
8/18/2019 Copy of Form SKP-Final
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8/18/2019 Copy of Form SKP-Final
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-ORMULIR SASARAN KERJA
PEGAWAI NEGERI SIPIL
NO I, PEJABAT PENILAI NO II, PEGAWAI NEGERI SIPIL *ANG DINILAI
1 Nama DERAH/AN, SP.// 1 Nama HARI WIDAYATI, S.KEP
2 NIP 1966009 199303 1 00 2 NIP 19710726 199403 2 002
3 Pa!"a#$G%&.R'a! PENATA TINGKAT I$ III ( 3 Pa!"a#$G%&.R'a! P*a#a T!"a# I$ III (
4 )aba#a KEPALA P+SKES/AS HA)I/ENA 4 )aba#a P*-a5a# P**&a
+# K*-a +PT.P+SKES/AS HA)I/ENA +# K*-a P'"*ma Ham*a
NO III, KEGIATAN TUGAS JABATAN AK TARGET
KUANT!OUTPUT KUAL!MUTU WAKTU BI
1 0.030 7.2 240 &a8%-a 100 12 b'&a
2 0.01 2.4 240 &a8%-a 100 12 b'&a
3 0.01 1.44 96 -'m'a 100 12 b'&a
4 0.02 4. 240 -'m'a 100 12 b'&a
/*-*caa"a #(a"a "*8*-a5a#a *(*-aa 8a(a "*&%m8%" 0.00 0.4 96 -*caa 100 12 b'&a
6 0.007 1.6 240 -*caa 100 12 b'&a
7 0.003 0.72 240 #(a"a 100 12 b'&a
0.01 2.4 240 #(a"a 100 12 b'&a
9 0.00 1.12 144 #(a"a 100 12 b'&a
10 /*&a"'"a 8*'&'a "*8a(a maa-a"a# 0.04 1.92 4 "*!a#a 100 12 b'&a
11 0.01 0.4 4 "a& 100 12 b'&a
12 0.007 0.4 120 &a8%-a 100 12 b'&a
., .. )a'a- 20
P*aba# P*&a, P*!a5a N*!*- S8& Ya! D&a
/*&a"aa"a 8*!"aa "*8*-a5a#a b*-'8a 8*!"aa (aa-8a(a maa-a"a#
/**-ma "%'a 8*!"aa "*8*-a5a#a b*-'8a 8*!"aa(aa-
/*&a"aa"a aa&a (a#a '#'" m*-'m'"a (a!%a"*8*-a5a#a aa&a *(*-aa 8a(a "*&%m8%"
/*&a"aa"a aa&a (a#a '#'" m*-'m'"a (a!%a"*8*-a5a#a aa&a *(*-aa 8a(a maa-a"a#
/*-*caa"a #(a"a "*8*-a5a#a *(*-aa 8a(amaa-a"a#
/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a(aa- 8a(a "a#a!%- II
/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a(aa- 8a(a "a#a!%- III
/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a"%m8&*" 8a(a "a#a!%- II
/*&a"aa"a *;a&'a "*8*-a5a#a *(*-aa "*8a(a"*&%m8%"
/**-ma "%'a *;a&'a "*8*-a5a#a *ca-a *(*-aa8a(a "*&%m8%"
8/18/2019 Copy of Form SKP-Final
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DERA)MAN+ SP,MM )ARI WIDA*ATI+ S,KEP
1966009 199303 1 00 19710726 199403 2 002
8/18/2019 Copy of Form SKP-Final
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Perhatian: Jika Tidak adaBiaya, Kolomini haruskosong(JANGAN diisiolehhuruf/angka/ta
nda baaa!a!un, "K :#
8/18/2019 Copy of Form SKP-Final
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PENILAIAN CAPAIAN SASARAN KERJA
PEGAWAI NEGERI SIPIL
)a!"a Wa"#' P*&aa
2 )a'a- $( 31 D**mb*- 2014
NO I, KEGIATAN TUGAS JABATAN AK TARGET
AK K'a#$ '#8'# Wa"#' aa
$ 2 # ( . / 0 1
1 7.2 240 100 12 b'&a ? 6.12 204
2 2.4 240 100 12 b'&a ? 1.1 11
3 1.44 96 100 12 b'&a ? 1.14 76
4 4. 240 100 12 b'&a ? 3.4 192
0.4 96 100 12 b'&a ? 0.40 1
6 1.6 240 100 12 b'&a ? 1.344 192
7 0.72 240 100 12 b'&a ? 0.612 204
2.4 192 100 12 b'&a ? 1.63 163
9 1.12 144 100 12 b'&a ? 0.976 122
10 /*&a"'"a 8*'&'a "*8a(a maa-a"a# 1.92 4 100 12 b'&a ? 1.2 3
11 0.4 4 "a& 100 12 b'&a ? 0.3 3 "a
12 0.4 120 100 12 b'&a ? 0.672 96
II, TUGAS TAMBA)AN DAN KREATI3ITAS 4
A Tuga Ta%&a5an 4
1
2
Kreati6ta
1
Nilai Ca7aian SKP
K'a&$/'#'
K'a#$'#8'#
/*&a"aa"a 8*!"aa "*8*-a5a#a b*-'8a 8*!"aa(aa- 8a(a maa-a"a#
&a8%-a
&a8%
/**-ma "%'a 8*!"aa "*8*-a5a#a b*-'8a8*!"aa (aa-
&a8%-a
&a8%
/*&a"aa"a aa&a (a#a '#'" m*-'m'"a (a!%a"*8*-a5a#a aa&a *(*-aa 8a(a "*&%m8%"
-'m'a
-'ma
/*&a"aa"a aa&a (a#a '#'" m*-'m'"a (a!%a"*8*-a5a#a aa&a *(*-aa 8a(a maa-a"a#
-'m'a
-'ma
/*-*caa"a #(a"a "*8*-a5a#a *(*-aa 8a(a"*&%m8%"
-*caa
-*ca
/*-*caa"a #(a"a "*8*-a5a#a *(*-aa 8a(amaa-a"a#
-*caa
-*ca
/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a
(aa- 8a(a "a#a!%- II
#(a"
a
#(
a/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a(aa- 8a(a "a#a!%- III
#(a"a
#(a
/*&a"aa"a #(a"a "*8*-a5a#a #(a"a "*8*-a5a#a"%m8&*" 8a(a "a#a!%- II
#(a"a
#(a
"*!a#a
"*!a
/*&a"aa"a *;a&'a "*8*-a5a#a *(*-aa "*8a(a"*&%m8%"
/**-ma "%'a *;a&'a "*8*-a5a#a *ca-a*(*-aa 8a(a "*&%m8%"
&a8%-a
&a8%
8/18/2019 Copy of Form SKP-Final
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a('!, 31 D
P*aba#
DERAH/A
1966009 19
8/18/2019 Copy of Form SKP-Final
13/24
8*-* 8*-* b"'a##a "'a&#a 5a"#' baa RWB24 RWC24 RB24 RC24
$# $(
246 2.00 1 2 0 76 76 100 2
DI$0 DI$0 1 0 0 47.917 0 76 76 100
DI$0 DI$0 1 0 0 79.167 0 76 76 100
DI$0 DI$0 1 0 0 0 0 76 76 100
DI$0 DI$0 1 0 0 4.37 76 76 100
DI$0 DI$0 1 0 0 0 76 76 100
DI$0 DI$0 1 0 0 76 76 100
DI$0 DI$0 1 0 0 4.96 76 76 100
DI$0 DI$0
1 0 0 4.722 76 76 100
DI$0 DI$0 1 0 0 79.167 0 76 76 100
DI$0 DI$0 1 0 0 79.167 0 76 76 100
DI$0 DI$0 1 0 0 0 0 76 76 100
@1.76=G?N$G=100
@1.76=I?P$I=100
0,2$ 12
8Baik9
PENG)ITUNGA
N
NILAICAPAIAN
SKP
BACK
TOMENUUTAMA
r5atian4 T(a" a(a R*a&aa, K%&%m a-'%! @)ANGAN ( '-'>$a!"a$#a(aca a8a8', K :
8/18/2019 Copy of Form SKP-Final
14/24
b*- 2014
&a,
2
P.//
3 1 00
8/18/2019 Copy of Form SKP-Final
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0.0000 246 246 246
0.0000 203.92 203.92 203.92
0.0000 23.17 23.17 23.17
0.0000 236 236 236
0.0000 24.3 24.3 24.3
0.0000 241 241 241
0.0000 246 246 246
0.0000 24.9 24.9 24.9
0.0000 24.72 24.72 24.72
0.0000 23.17 23.17 23.17
0.0000 23.17 23.17 23.17
0.0000 236 236 236
@76?@@@@1.76=G?N$G=100?100
@76?@@@@1.76=I?P$I=100?100
8/18/2019 Copy of Form SKP-Final
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BUKU CATATAN PENILAIAN PERILAKU PNS
Nama : HARI WIDAYATI, S.KEP
NIP : 19710726 199403 2 002
N% Ta!!a& +-aa
1 2 3 4
1 P*&aa SKP am8a (*!a a"- D**mb*- 2014 F
79.21 *(a!"a 8*&aa 8*-&a"' "*-aa a(a&a
*ba!a b*-"'# :
-*#a P*&aaa F 0.00 @a"
I#*!-#a F 79.00 @a"
K%m#m* F .00 @a"
D8& F .00 @a"
K*-aama F 0.00 @a" DERAH/AN, SP.//
K*8*mm8a F 0.00 @a" 1966009 199303 1 00
)'m&a F 49
N&a Ra#a?-a#a F 1.0 @a"
Nama$NIP (a Pa-a>P*aba# P*&a
2 )a'a- $(31 D**mb*-
2014
KEPALA P+SKES/ASHA)I/ENA
8/18/2019 Copy of Form SKP-Final
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PENILAIAN PRESTASI KERJAPEGAWAI NEGERI SIPIL
)ANGKA WAKT+ PENILAIAN
ADAN KEPEGAWAIAN NEGARA 2 )a'a- $( 31 D**mb*- 2014
1. YANG DINILAI
a. N A / A )ARI WIDA*ATI+ S,KEP
b. NIP 19710726 199403 2 002
c. Pa!"a#, !%&%!a -'a! P*a#a T!"a# I$ III (
(. )aba#a$P*"*-aa P*-a5a# P**&a
*. +# -!aa P'"*ma Ham*a
2. PE)AAT PENILAI
a. N A / A DERA)MAN+ SP,MM
b. NIP 1966009 199303 1 00
c. Pa!"a#, !%&%!a -'a! PENATA TINGKAT I$ III (
(. )aba#a$P*"*-aa KEPALA P+SKES/AS HA)I/ENA
*. +# -!aa +PT.P+SKES/AS HA)I/ENA
3. ATASAN PE)AAT PENILAI
a. N A / A A)MAD ROD)I+ SKM,M,KES
b. NIP 196200 1903 1 00
c. Pa!"a#, !%&%!a -'a! PE/INA TINGKAT I $ I b
(. )aba#a$P*"*-aa SEKERTARIS DINAS KESEHATAN LA/SEL
*. +# -!aa DINAS KESEHATAN LA/P+NG SELATAN
4. +NS+R YANG DINILAI )+/LAH
a. Saa-a K*-a P*!a5a @SKP 79.21 60 47.2
1. -*#a P*&aaa 0.00 @a"
2. I#*!-#a 79.00 @a"
3. K%m#m* .00 @a"
8/18/2019 Copy of Form SKP-Final
20/24
b.
4 D8& .00 @a"
. K*-aama 0.00 @a"
6. K*8*mm8a 0.00 @a"
)'m&a 49.00 0
N&a Ra#a?-a#a 1.0 @a"
N&a P*-&a"' "*-a 1.0 40 32.60
N&a P-*#a K*-a0.12
@a"
. KEERATAN DARI PEGAWAI NEGERI SIPIL Ta!!a& ................................
YANG DINILAI @APAILA ADA
6. TANGGAPAN PE)AAT PENILAI ATAS KEERATAN Ta!!a& ................................
7. KEP+T+SAN ATASAN PE)AAT PENILAI ATAS Ta!!a& ................................
KEERATAN
. REK/ENDASI Ta!!a& ................................
10. DITERI/A TANGGAL,9. DI+AT TANGGAL,
PEGAWAI NEGERI SIPIL YANG PE)AAT PENILAI
DINILAI,
DERAH/AN, SP.//
HARI WIDAYATI, S.KEP 1966009 199303 1 00
19710726 199403 2 00211. DITERI/A TANGGAL,
ATASAN PE)AAT YANG /ENILAI
P*-&a"'K*-a
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AH/AD RDHI, SK/./.KES
196200 1903 1 00
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