| IDENTITAS IDUKA | |
| Nama IDUKA | : RSU Muhammadiyah Babat |
| Alamat IDUKA | : Jl. Raya Babat - Surabaya No.Km. 4 Babat Kec. Babat, Kabupaten Lamongan, Jawa Timur 62271 |
| Pelaksanaan | : 14 Oktober 2025 s/d 13 Januari 2026 |
| Nama Direktur/ Pimpinan *) | : ........................................................................ |
| Nama Pembimbing *) | : ........................................................................ |
| No HP/ WA Pembimbing | : ........................................................................ |
| IDENTITAS PESERTA | |
| Nama Siswa | : WIDYA TRI HAPSARI / XII AKC |
| HP Siswa | : 085895400286 |
| HP Orangtua | : 081333598260 |
| 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 : |