ASSESMENT KOMPETENSI

KOLEGIUM DOKTER PRIMER INDONESIA

HARI/TANGGAL

SABTU - RABU, 17 21 MEI 2014

PETUNJUK
1. Assesment kompetensi hanya diperuntukkan bagi lulusan UKDI Februari 2014 (lulus
CBT dan OSCE)
2. Isilah biodata terlampir dilengkapi dengan foto warna ukuran 4 x 6 cm
3. Assesment kompetensi ini memuat empat materi, antara lain :
a. Kebijakan Jaminan Kesehatan Nasional dan Manual Penyelenggaraan Praktik
b. Komunikasi Efektif
c. Formularium Nasional
d. Kode Etik Kedokteran Indonesia
4. Total soal sebanyak 20 (dua puluh) soal dengan masing-masing materi memiliki 5 (lima)
soal.
5. Pilihlah 1 (satu) soal yang dijawab dari 5 (lima) soal masing-masing materi.
6. Total jumlah soal yang yang harus dijawab adalah 4 (empat) soal, dengan perincian 1
soal materi Kebijakan Jaminan Kesehatan Nasional dan Manual Penyelenggaraan
Praktik, 1 soal Komunikasi Efektif, 1 soal Formularium Nasional dan 1 Soal Kode Etik
Kedokteran Indonesia.
7. Isilah tanggal mengerjakan, nomor halaman, nama dan asal universitas pada setiap
lembar jawaban (bisa memperbanyak lembar jawaban jika lebih dari satu halaman)
8. Jawablah pertanyaan pada lembar jawaban terlampir (tidak timbal balik) menggunakan
ballpoint dengan tulisan tangan sendiri.
9. Tulisan tangan harus jelas dan mudah dibaca.
10. Bekerjalah sendiri. Setiap peserta terindikasi melakukan kecurangan akan dianggap
gugur.
11. Isilah surat pernyataan terlampir dan ditanda tangani di atas materai Rp 6.000,12. Seluruh dokumen jawaban dikirim paling lambat tanggal 21 Mei 2014 (cap pos) ke alamat
:
Kolegium Dokter Primer Indonesia
Jalan Sam Ratulangi No. 29 Menteng Jakarta Pusat
Telp. (021) 3140816
13. Dokumen jawaban terdiri atas :
a. Biodata
b. Surat Pernyataan Mengerjakan Sendiri
c. Jawaban Materi Kebijakan Jaminan Kesehatan Nasional dan Manual
Penyelenggaraan Praktik
d. Jawaban Materi Komunikasi Efektif
e. Jawaban Materi Formularium Nasional
f. Jawaban Materi Kode Etik Kedokteran Indonesia
14. Jawaban yang sampai melewati waktu yang ditentukan tidak akan diterima.

FOTO 4 x 6 cm
WARNA

BIODATA PESERTA
ASSESMENT KOMPETENSI
KOLEGIUM DOKTER PRIMER INDONESIA

1. N a m a

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2. Nomor KTP

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3. Tempat / Tanggal Lahir :

.......................................................................................

4. Jenis Kelamin

Laki-Laki/ Perempuan *coret yang tidak perlu

5. Agama

.......................................................................................

6. Alamat Rumah

.......................................................................................
.......................................................................................
.......................................................................................
Kode Pos...................... Telepon : (.............) ..................

7. Alamat Korespondensi

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Kode Pos...................... Telepon : (.............) ..................

8. Nomor HP

.......................................................................................

9. E-mail

.......................................................................................

10. Asal Universitas

.......................................................................................

11. Tahun

Masuk : ............................. Lulus : .................................

12. IPK

Sarjana : ........................... Dokter : ...............................

..............................., ..................................... 2014

Yang Membuat,

(.....................................................................)

SURAT PERNYATAAN MENGERJAKAN SENDIRI

ASSESMENT KOMPETENSI
KOLEGIUM DOKTER PRIMER INDONESIA

Yang bertanda tangan di bawah ini :

Nama

.......................................................................................

Asal Universitas

.......................................................................................

Menyatakan bahwa :
1. Jawaban soal Assesment Kompetensi ini dibuat dengan tulisan tangan sendiri, dengan
sejujurnya, mengikuti kaidah Etika Akademik serta menjamin bebas Plagiarisme.
2. Saya juga menyadari bahwa jika saya tidak menandatangani surat pernyataan ini
berarti saya tidak berkontribusi dalam pembuatan jawaban soal Assesment
Kompetensi serta bersedia menerima segala konsekuensi karena keteledoran
tersebut.
3. Bila kemudian diketahui saya melanggar, maka saya bersedia dinyatakan tidak
lulus/gagal serta bersedia menerima segala konsekuensi yang disyaratkan oleh
Kolegium Dokter Primer Indonesia.
4. Bila di kemudian hari saya terbukti melanggar, maka saya bersedia menerima sanksi
berupa pencabutan sertifikat kompetensi dengan segala dampak dan akibatnya.
..............................., ..................................... 2014
Yang Membuat,
MATERAI
Rp 6000

(.....................................................................)

Tanggal Mengerjakan : .....................................................

Halaman : ..................................

Nama : ........................................................ Asal Universitas : ..............................................

LEMBAR JAWABAN
MATERI KEBIJAKAN JAMINAN KESEHATAN NASIONAL DAN
MANUAL PENYELENGGARAAN PRAKTIK
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Tanggal Mengerjakan : .....................................................

Halaman : ..................................

Nama : ........................................................ Asal Universitas : ..............................................

LEMBAR JAWABAN
MATERI KOMUNIKASI EFEKTIF
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Tanggal Mengerjakan : .....................................................

Halaman : ..................................

Nama : ........................................................ Asal Universitas : ..............................................

LEMBAR JAWABAN
MATERI FORMULARIUM NASIONAL
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Tanggal Mengerjakan : .....................................................

Halaman : ..................................

Nama : ........................................................ Asal Universitas : ..............................................

LEMBAR JAWABAN
MATERI KODE ETIK KEDOKTERAN INDONESIA
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