{"id":156,"date":"2019-04-02T02:21:06","date_gmt":"2019-04-02T02:21:06","guid":{"rendered":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/?page_id=156"},"modified":"2022-09-13T03:59:24","modified_gmt":"2022-09-13T03:59:24","slug":"form-surat-ijin-lokasi-praktik","status":"publish","type":"page","link":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/poltekkes-kemenkes-banjarmasin-jurusan-kesehatan-lingkungan-2\/form-surat-ijin-lokasi-praktik\/","title":{"rendered":"FORM SURAT IJIN LOKASI PRAKTIK"},"content":{"rendered":"\n<script src=\"https:\/\/cdn02.jotfor.ms\/static\/prototype.forms.js?3.3.35793\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn03.jotfor.ms\/static\/jotform.forms.js?3.3.35793\" type=\"text\/javascript\"><\/script>\n<script src=\"https:\/\/cdn01.jotfor.ms\/js\/vendor\/imageinfo.js?v=3.3.35793\" type=\"text\/javascript\"><\/script>\n<script 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form-label-auto\" id=\"label_17\" for=\"input_17\"> Hari, pelaksanaan <\/label>\n        <div id=\"cid_17\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_17\" name=\"q17_hariPelaksanaan\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_17 sublabel_input_17\" \/>\n            <label class=\"form-sub-label\" for=\"input_17\" id=\"sublabel_input_17\" style=\"min-height:13px\" aria-hidden=\"false\"> contoh : Rabu, 09 Maret 2019 Atau ketik : Lihat lampiran (jika tanggal pelaksaan berbeda-beda) <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_18\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_18\" for=\"input_18\"> Waktu <\/label>\n        <div id=\"cid_18\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_18\" name=\"q18_waktu\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_18 sublabel_input_18\" \/>\n            <label class=\"form-sub-label\" for=\"input_18\" id=\"sublabel_input_18\" style=\"min-height:13px\" aria-hidden=\"false\"> Contoh : Jam 08.00 &#8211; 12.00 Wita Atau ketik : Lihat lampiran (jika waktu pelaksaan berbeda-beda) <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_19\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_19\" for=\"input_19\"> Jumlah Peserta <\/label>\n        <div id=\"cid_19\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_19\" name=\"q19_jumlahPeserta\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_19 sublabel_input_19\" \/>\n            <label class=\"form-sub-label\" for=\"input_19\" id=\"sublabel_input_19\" style=\"min-height:13px\" aria-hidden=\"false\"> contoh : 40 orang <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_10\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_10\" for=\"input_10\"> Tembusan <\/label>\n        <div id=\"cid_10\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_10\" name=\"q10_tembusan\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"50\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_10 sublabel_input_10\" \/>\n            <label class=\"form-sub-label\" for=\"input_10\" id=\"sublabel_input_10\" style=\"min-height:13px\" aria-hidden=\"false\"> diisi jika ada <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_11\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_11\" for=\"input_11\"> Lampiran <\/label>\n        <div id=\"cid_11\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <select class=\"form-dropdown\" id=\"input_11\" name=\"q11_lampiran\" style=\"width:150px\" data-component=\"dropdown\">\n              <option value=\"\">  <\/option>\n              <option value=\"-\"> &#8211; <\/option>\n              <option value=\"Satu Lembar\"> Satu Lembar <\/option>\n              <option value=\"Dua Lembar\"> Dua Lembar <\/option>\n              <option value=\"Tiga Lembar\"> Tiga Lembar <\/option>\n              <option value=\"Empat Lembar \"> Empat Lembar <\/option>\n              <option value=\"Lima Lembar\"> Lima Lembar <\/option>\n            <\/select>\n            <label class=\"form-sub-label\" for=\"input_11\" id=\"sublabel_input_11\" style=\"min-height:13px\" aria-hidden=\"false\"> jumlah lampiran <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_15\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_15\" for=\"input_15\">\n          Pengusul\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_15\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_15\" name=\"q15_pengusul15\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"25\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_15 sublabel_input_15\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_15\" id=\"sublabel_input_15\" style=\"min-height:13px\" aria-hidden=\"false\"> nama pengusul <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_14\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_14\" for=\"input_14\">\n          Bulan dikeluarkan surat\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_14\" class=\"form-input jf-required\">\n          <select class=\"form-dropdown validate[required]\" id=\"input_14\" name=\"q14_bulanDikeluarkan\" style=\"width:150px\" data-component=\"dropdown\" required=\"\">\n            <option value=\"\">  <\/option>\n            <option value=\"Januari\"> Januari <\/option>\n            <option value=\"Februari\"> Februari <\/option>\n            <option value=\"Maret\"> Maret <\/option>\n            <option value=\"April\"> April <\/option>\n            <option value=\"Mei\"> Mei <\/option>\n            <option value=\"Juni\"> Juni <\/option>\n            <option value=\"Juli\"> Juli <\/option>\n            <option value=\"Agustus\"> Agustus <\/option>\n            <option value=\"September\"> September <\/option>\n            <option value=\"Oktober\"> Oktober <\/option>\n            <option value=\"November\"> November <\/option>\n            <option value=\"Desember\"> Desember <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_22\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_22\" for=\"input_22\">\n          Nama dan Kontak Person Pembimbing Praktik\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_22\" class=\"form-input jf-required\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_22\" name=\"q22_namaDan\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_22 sublabel_input_22\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_22\" id=\"sublabel_input_22\" style=\"min-height:13px\" aria-hidden=\"false\"> contoh : Pahruddin, HP\/WA : 0812-5122-2211 <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textarea\" id=\"id_13\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_13\" for=\"input_13\"> Catatan <\/label>\n        <div id=\"cid_13\" class=\"form-input\">\n          <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n            <textarea id=\"input_13\" class=\"form-textarea\" name=\"q13_catatan\" cols=\"40\" rows=\"6\" data-component=\"textarea\" aria-labelledby=\"label_13 sublabel_input_13\"><\/textarea>\n            <label class=\"form-sub-label\" for=\"input_13\" id=\"sublabel_input_13\" style=\"min-height:13px\" aria-hidden=\"false\"> diisi jika ada keperluan lain <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fileupload\" id=\"id_21\">\n        <label class=\"form-label form-label-left form-label-auto\" id=\"label_21\" for=\"input_21\"> Lampiran <\/label>\n        <div id=\"cid_21\" class=\"form-input\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container\" style=\"vertical-align:top\">\n              <div class=\"qq-uploader-buttonText-value\">\n                Browse Files\n              <\/div>\n              <input type=\"file\" id=\"input_21\" name=\"q21_lampiran21[]\" multiple=\"\" class=\"form-upload-multiple\" data-imagevalidate=\"yes\" data-file-accept=\"pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif\" data-file-maxsize=\"10854\" data-file-minsize=\"0\" data-file-limit=\"\" data-component=\"fileupload\" \/>\n              <label class=\"form-sub-label\" for=\"input_21\" style=\"min-height:13px\" aria-hidden=\"false\"> upload file jika ada lampiran surat <\/label>\n            <\/span>\n            <span style=\"display:none\" class=\"cancelText\">\n              Cancel\n            <\/span>\n            <span style=\"display:none\" class=\"ofText\">\n              of\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_2\">\n        <div id=\"cid_2\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px\" data-align=\"auto\" class=\"form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField\">\n            <button id=\"input_2\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">\n              Submit\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"new_footer\";\n  <\/script>\n  <script>\n  JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script>\n  <input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"90621616943458\" \/>\n  <script type=\"text\/javascript\">\n  var all_spc = document.querySelectorAll(\"form[id='90621616943458'] .si\" + \"mple\" + \"_spc\");\nfor (var i = 0; i < all_spc.length; i++)\n{\n  all_spc[i].value = \"90621616943458-90621616943458\";\n}\n  <\/script>\n  <div class=\"formFooter-heightMask\">\n  <\/div>\n  <div class=\"formFooter f6 branding21\">\n    <div class=\"formFooter-wrapper formFooter-leftSide\">\n      <a href=\"https:\/\/www.jotform.com\/?utm_source=formfooter&#038;utm_medium=banner&#038;utm_term=90621616943458&#038;utm_content=jotform_logo&#038;utm_campaign=powered_by_jotform_le\" target=\"_blank\" class=\"formFooter-logoLink\" rel=\"noopener\"><img decoding=\"async\" class=\"formFooter-logo\" src=\"https:\/\/cdn.jotfor.ms\/assets\/img\/logo2021\/jotform-logo-white.svg\" alt=\"Jotform Logo\" style=\"height: 44px;\"><\/a>\n    <\/div>\n    <div class=\"formFooter-wrapper formFooter-rightSide\">\n      <span class=\"formFooter-text\">\n        Now create your own Jotform - It's free!\n      <\/span>\n      <a class=\"formFooter-button\" href=\"https:\/\/www.jotform.com\/?utm_source=formfooter&#038;utm_medium=banner&#038;utm_term=90621616943458&#038;utm_content=jotform_button&#038;utm_campaign=powered_by_jotform_le\" target=\"_blank\" rel=\"noopener\">Create your own Jotform<\/a>\n    <\/div>\n  <\/div>\n<\/form>\n","protected":false},"excerpt":{"rendered":"<p>FORM SURAT IJIN LOKASI PRAKTIK POLTEKKES KEMENKES BANJARMASIN JURUSAN KESEHATAN LINGKUNGAN Yth * contoh : Direktur PDAM Intan Banjar Nama<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":806,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-156","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/pages\/156","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/comments?post=156"}],"version-history":[{"count":7,"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/pages\/156\/revisions"}],"predecessor-version":[{"id":1335,"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/pages\/156\/revisions\/1335"}],"up":[{"embeddable":true,"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/pages\/806"}],"wp:attachment":[{"href":"https:\/\/akademik.kesling-poltekkesbjm.com\/akademik\/wp-json\/wp\/v2\/media?parent=156"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}