| IDENTITAS IDUKA | |
| Nama IDUKA | : RS. Muhammadiyah Lamongan |
| Alamat IDUKA | : Jl. Jaksa Agung Suprapto No.76, Sarirejo, Sukorejo, Kec. Lamongan, Kabupaten Lamongan, Jawa Timur 62215 |
| Pelaksanaan | : 1 September s/d 31 Desember 2025 |
| Nama Direktur/ Pimpinan *) | : ........................................................................ |
| Nama Pembimbing *) | : ........................................................................ |
| No HP/ WA Pembimbing | : ........................................................................ |
| IDENTITAS PESERTA | |
| Nama Siswa | : ANGGUN CITRA LESTARI / XII FKK |
| HP Siswa | : 08813273146 |
| HP Orangtua | : 088235542876 |
| No | Tanggal Kunjungan | Uraian Kegiatan | Catatan | Paraf/stempel Pembimbing IDUKA | Petugas Monitoring |
| 1 | |||||
| 2 | |||||
| 3 |
| Hasil Pelaksanaan PKL :
.............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................................. |
| Panitia PKL .................... NBM : |