| 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 | : NADYA DWI ARTANTI / XII FKK |
| HP Siswa | : 081333778528 |
| HP Orangtua | : 082231609828 |
| No | Tanggal Kunjungan | Uraian Kegiatan | Catatan | Paraf/stempel Pembimbing IDUKA | Petugas Monitoring |
| 1 | |||||
| 2 | |||||
| 3 |
| Hasil Pelaksanaan PKL :
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| Panitia PKL .................... NBM : |