[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-id-113":3,"doc-seo-234107-113":41,"doc-detail-234107-id":114},{"code":4,"msg":5,"data":6},0,"success",[7,13,17,21,25,29,33,37],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":4,"slug":12},178,1,"Template","Faktur","faktur",{"id":14,"doc_module":9,"doc_module_name":10,"category_name":15,"show_sort_weight":4,"slug":16},192,"Formulir","formulir-192",{"id":18,"doc_module":9,"doc_module_name":10,"category_name":19,"show_sort_weight":4,"slug":20},180,"Media Sosial","media-sosial",{"id":22,"doc_module":9,"doc_module_name":10,"category_name":23,"show_sort_weight":4,"slug":24},179,"Poster","poster",{"id":26,"doc_module":9,"doc_module_name":10,"category_name":27,"show_sort_weight":4,"slug":28},176,"Presentasi","presentasi",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":4,"slug":32},177,"Resume","resume",{"id":34,"doc_module":9,"doc_module_name":10,"category_name":35,"show_sort_weight":4,"slug":36},182,"Surat","surat-a95d00d3aaf04f3b854ecf140f00d385",{"id":38,"doc_module":9,"doc_module_name":10,"category_name":39,"show_sort_weight":4,"slug":40},183,"Umum","umum-07d1ff437201438088836b2b1ed3c90f",{"code":4,"msg":42,"data":43},"ok",{"site_id":44,"language":45,"slug":46,"title":47,"keywords":48,"description":49,"schema_data":50,"social_meta":107,"head_meta":109,"extra_data":111,"updated_unix":113},113,"id","cardiovascular-technician-sip-form-sip-tkv-application-for-practice-permit-and-supervisor-statement","Form SIP Teknisi Kardiovaskuler (SIP-TKV) - Permohonan Surat Izin Praktik dan Surat Pernyataan Pimpinan","","Form Permohonan Surat Izin Praktik Teknisi Kardiovaskuler (SIP-TKV) untuk diajukan kepada Kepala Dinas Kesehatan Kota Bandung. Form ini memuat identitas pemohon, data STR-TKV dan masa berlaku, riwayat pendidikan, serta alamat dan wilayah kerja pada fasilitas pelayanan kesehatan (Tempat Bekerja 1 dan 2). Dilengkapi lampiran persyaratan seperti legalisasi ijazah, STR-TKV, surat keterangan sehat fisik, rekomendasi organisasi profesi, pas foto, E-KTP/SKTS, fotokopi SIP-TKV, izin operasional fasyankes, serta surat pernyataan tidak keberatan dari pimpinan untuk PNS/TNI/POLRI/BUMN/Badan Hukum.",{"@graph":51,"@context":106},[52,68,89],{"@type":53,"itemListElement":54},"BreadcrumbList",[55,59,62,65],{"item":56,"name":57,"@type":58,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":60,"name":10,"@type":58,"position":61},"https://docshare.wps.com/id/template/",2,{"item":63,"name":15,"@type":58,"position":64},"https://docshare.wps.com/id/template/formulir/",3,{"item":66,"name":47,"@type":58,"position":67},"https://docshare.wps.com/id/template/cardiovascular-technician-sip-form-sip-tkv-application-for-practice-permit-and-supervisor-statement/234107/",4,{"url":66,"name":47,"@type":69,"image":70,"author":75,"headline":47,"publisher":78,"fileFormat":81,"inLanguage":45,"description":49,"dateModified":82,"datePublished":83,"encodingFormat":81,"isAccessibleForFree":84,"interactionStatistic":85},"DigitalDocument",{"url":71,"@type":72,"width":73,"height":74},"https://docshare.wps.com/thumbnails/cardiovascular-technician-sip-form-sip-tkv-application-for-practice-permit-and-supervisor-statement/234107.png","ImageObject",442,249,{"name":76,"@type":77},"Kyle","Person",{"url":56,"name":79,"@type":80},"DocShare","Organization","application/pdf","2026-09-20","2026-09-10",true,{"@type":86,"interactionType":87,"userInteractionCount":61},"InteractionCounter",{"@type":88},"ViewAction",{"@type":90,"mainEntity":91},"FAQPage",[92,98,102],{"name":93,"@type":94,"acceptedAnswer":95},"Dokumen apa saja yang perlu dilampirkan untuk permohonan SIP-TKV?","Question",{"text":96,"@type":97},"Lampiran mencakup fotokopi ijazah yang dilegalisasi, fotokopi STR-TKV atau STR-TKV sementara, surat keterangan sehat fisik dari dokter, surat keterangan bekerja, surat rekomendasi organisasi profesi, pas foto 3x4 cm, serta dokumen identitas E-KTP/SKTS.","Answer",{"name":99,"@type":94,"acceptedAnswer":100},"Bagaimana cara mengisi data tempat praktik untuk SIP-TKV?",{"text":101,"@type":97},"Pemohon mengisi Tempat Bekerja 1 dan/atau Tempat Bekerja 2, termasuk nama sarana, alamat (jalan, RT/RW, kelurahan), wilayah kerja puskesmas, serta kecamatan.",{"name":103,"@type":94,"acceptedAnswer":104},"Apa isi surat pernyataan pimpinan dalam form ini?",{"text":105,"@type":97},"Surat pernyataan pimpinan menyatakan tidak keberatan memberikan izin kepada nama tertentu untuk menjalankan praktik perawat di luar tempat bekerja, selama sesuai peraturan dan tidak mengganggu tugas kedinasan.","https://schema.org",{"og:url":66,"og:type":108,"og:title":47,"og:site_name":79,"og:description":49},"article",{"robots":110,"canonical":66},"index,follow",{"doc_id":112,"site_id":44},234107,1789083722,{"code":4,"msg":5,"data":115},{"doc_id":112,"user_id":116,"nickname":76,"user_avatar":117,"doc_module":9,"category_id":14,"category_name":15,"doc_title":47,"doc_description":49,"doc_content":118,"file_id":119,"file_url":120,"file_type":121,"file_size":122,"view_count":61,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":67,"language":123,"language_code":45,"site_id":44,"html_lang":45,"table_of_contents":124,"faqs":125,"seo_title":126,"seo_description":49,"update_tm":113,"read_time":61},3985741905716,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Perihal : Permohonan Surat Izin Praktik Teknisi Kardiovaskuler (SIP-TKV)  \nKepada Yth :  \nKepala Dinas Kesehatan Kota Bandung Jl.Supratman No.73  \ndi –  \nB a n d u n g  \nDengat Hormat,  \nNama Lengkap : ................................... ................................................... ....................  \nTempat, Tgl.Lahir : .............................. ................................................... .........................  \nNo. STR-TKV : .................................... ................................................... ...................  \nMasa berlaku STR-TKV : ........................... ................................................... ............................  \nLulusan : ....................................................................... Tahun ............. ...........  \nNama Sekolah : ................................... ................................................... ....................  \nAlamat Rumah : Jl ................................. ................................................... ....................  \nRT / RW ...................................... Kelurahan/Desa .............................  \nKecamatan................................... Kota/Kabupaten .............................  \nTelepon / HP................................ Kode Pos ........................................  \nNo.HP : .......................................... ................................................... .............  \nDengan ini mengajukan permohonan untuk mendapatkan Surat Izin Praktik Teknisi Kardiovaskuler (SIP-TKV) yg berlokasi di :  \nTempat Bekerja 1 : .................................................................................... (tulis nama sarana)  \nJl .............................................. ...................................................    \nRT / RW ............... Kelurahan ................ ..............................................  \nWilayah Kerja Puskesmas ......................... ..........................................  \nKecamatan ........................................ ..................................................  \nTempat Bekerja 2 : .................................................................................... (tulis nama sarana)  \nJl .............................................. ...................................................    \nRT / RW ............... Kelurahan ................ ..............................................  \nWilayah Kerja Puskesmas ......................... ..........................................  \nKecamatan ........................................ ..................................................  \nSebagai bahan pertimbangan, bersama ini kami lampirkan :  \n1.  \n2.  \n3.  \n4.  \n5.  \n6.  \n7.  \n8.  \n9.  \n10  \nFotocopy Izajah yang dilegalisasi Asli  \nFotocopy STR-TKV atau STR-TKV sementara bagi Nakes WNA yang dilegalisir asli & masih berlaku Surat keterangan sehat fisik dari dokter yang memiliki Surat Izin Praktik  \nSurat keterangan bekerja dari Fasilitas Pelayanan Kesehatan yang bersangkutan Surat Rekomendasi dari organisasi profesi  \nPas foto berwarna terbaru ukuran 3 X 4 cm sebanyak 4 (empat) lembar latar Merah  \nPhoto copy E-KTP Kota Bandung/ Surat Keterangan Tinggal sementara di Kota Bandung (SKTS) dari disdukcapil (bagi Tenaga Teknisi Kardiovaskuler dengan E-KTP luar Kota Bandung melampirkan surat pengantar/rekomendasi dari Dinas Kesehatan setempat yg menyatakan belum /sudah berpraktik di wilayah tersebut) .  \nFotocopy SIP-TKV yang dimiliki  \nFotocopy Izin Operasional Fasyankes yang masih berlaku.  \nSurat pernyataan tidak keberatan / izin dari Pimpinan tempat bekerja bagi PNS/TNI/ POLRI / BUMN / BADAN HUKUM.  \nDemikian permohonan ini kami ajukan, atas perhatiannya kami ucapkan terima kasih.  \nBandung, ...................................... Pemohon,  \nNama Lengkap  \nSURAT PERNYATAAN PIMPINAN  \nYang bertanda tangan dibawah ini :  \nNama Lengkap : ................................... ..................................","cbCaitvSIBbiDMG5","https://ap.wps.com/l/cbCaitvSIBbiDMG5","pdf",53514,"Indonesian","# Permohonan Surat Izin Praktik Teknisi Kardiovaskuler (SIP-TKV)\n## Identitas Pemohon\n## Data STR-TKV dan Masa Berlaku\n## Data Lulusan dan Alamat\n## Tempat Bekerja (1 dan 2)\n## Lampiran Persyaratan\n# Surat Pernyataan Pimpinan","[{\"question\":\"Dokumen apa saja yang perlu dilampirkan untuk permohonan SIP-TKV?\",\"answer\":\"Lampiran mencakup fotokopi ijazah yang dilegalisasi, fotokopi STR-TKV atau STR-TKV sementara, surat keterangan sehat fisik dari dokter, surat keterangan bekerja, surat rekomendasi organisasi profesi, pas foto 3x4 cm, serta dokumen identitas E-KTP/SKTS.\"},{\"question\":\"Bagaimana cara mengisi data tempat praktik untuk SIP-TKV?\",\"answer\":\"Pemohon mengisi Tempat Bekerja 1 dan/atau Tempat Bekerja 2, termasuk nama sarana, alamat (jalan, RT/RW, kelurahan), wilayah kerja puskesmas, serta kecamatan.\"},{\"question\":\"Apa isi surat pernyataan pimpinan dalam form ini?\",\"answer\":\"Surat pernyataan pimpinan menyatakan tidak keberatan memberikan izin kepada nama tertentu untuk menjalankan praktik perawat di luar tempat bekerja, selama sesuai peraturan dan tidak mengganggu tugas kedinasan.\"}]","Form SIP Teknisi Kardiovaskuler (SIP-TKV) - Permohonan Surat Izin Praktik dan Surat Pernyataan Pimpinan | PDF"]