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Screening Kesehatan
Anda harus JUJUR dalam menjawab pertanyaan di bawah ini.
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Nama
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Nomor Daftar Hadir (NDH)
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contoh: 01, 04, 25, 40, dsb.
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Jenis Kelamin
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Pria
Wanita
Tempat, Tanggal Lahir
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Nama Instansi
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NIP
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