PEMERIKSAAN PERSEDIAAN OBAT-OBATAN / ALAT PPPK KAPAL

( Di isi oleh Petugas Kesehatan Pelabuhan )

Pada hari ini, ............................ tanggal : ............................ telah diadakan pemeriksaan obat-obatan /

PPPK oleh Petugas Kantor Kesehatan Pelabuhan Kelas I Tanjung Priok terhadap :

1 Nama Kapal :

2 Agen / Pemilik :

3 Bendera :

4 Jumlah Awak Kapal :

5 Jumlah Sekoci :

Pada saat pemeriksaan :

1 Kotak Obat : Ada Tidak ada

2 Jenis Obat : Lengkap Tidak lengkap

3 Jumlah Obat : Cukup Tidak cukup

4 Expire Date : Berlaku Tidak berlaku

5 Keadaan Fisik Obat : Baik Tidak baik

6 Etiket pada obat : Ada Tidak ada

7 Buku Petunjuk P3K : Ada Tidak ada

8 Alat P3K (daftar keterangan

alat P3K terlampir)

: Ada Tidak ada

SARAN : 1. ................................................................................................................................

2. ................................................................................................................................

3. ................................................................................................................................

4. ................................................................................................................................

5. ................................................................................................................................

DASAR HUKUM: 1. UU RI nomor 21 tahun 1992 tentang Pelayaran

2. SK Men.Kes No. 265 tahun 2004 tentang Organisasi dan Tata Kerja KKP

3. International Medical Guide for Ships,Second Edition,WHO, 1988

Mengetahui Nakhoda/Perwira Jaga,

(…………………………)

Tanjung Priok………………….. Petugas Pemeriksa,

(…................................... )

INSPECTION OF MEDICINE SUPPLY / FIRST AIDS APPLIANCE IN SHIP.

( Content by Port Health Officer )

On this day , ….................... date of , ……………….. Have been performed by inspection of Medicine

Supply / First aids appliance by Port Health Office Class I Tanjung Priok Officer to :

1. Name of ship :

2. Agent / Owner :

3. Nationality / Flag :

4. Number of crew :

5. Number of Life boat :

at the (time) of inspection :

1 Box of Medicine : Yes No

2 Type of Medicine : Complete No

3 Number of Medicine : Enough No

4 Expire Date : Good No

5 Condition of Medicine Physical : Good No

6 Etiquette at Medicine : Yes No

7 First Aids reference book : Yes No

8 First Aids Appliance ( List enclosed ) : Yes No

Suggestion :

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

……………………………………………………………………………………………………………

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Legal Fundament :

1. Code No. 21,1992 about Sea Transport

2. Decree Minister of Health No. 265, 2004 about Office Administration and Organization Port Health

Office Class I Tanjung Priok

3. International Medical Guide for Ship, second Edition, WHO, 1988

Knowing Tanjung Priok, ……………………..

Master / Duty Officer Inspection Officer

( …………..…………. ) ( …………………………. )