1.

Apakah anda/keluarga pernah mendapatkan pelayanan di puskesmas

Pleret?
a. Belum
b. Pernah. Karena
penyakit :...............................................................................................
2. Bagaimana pendapat anda/keluarga tentang bangunan dan sarana yang
ada di Puskesmas Pleret?
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3. Apakah anda/keluarga pernah mendapatkan pelayanan Pendaftaran &
kasir Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ..........................................
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4. Apakah anda/keluarga pernah mendapatkan pelayanan di BP Umum
Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut: ...................................
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5. Apakah anda/keluarga pernah mendapatkan pelayanan di BP Gigi
Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut: ...................................
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6. Apakah anda/keluarga pernah mendapatkan pelayanan di bagian KIA KB
Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ..........................................
7. ......................................................................................................................
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8. Apakah anda/keluarga pernah mendapatkan pelayanan di bagian
laboratorium Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ...................

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9. Apakah anda/keluarga pernah mendapatkan pelayanan di bagian
Farmasi/obat Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ..........................................
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10.Apakah anda/keluarga pernah mendapatkan pelayanan balita/MTBS di

Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ..........................................
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11.Apakah anda/keluarga pernah mendapatkan pelayanan fisioterapi di
Puskesmas Pleret?
c. Belum pernah
d. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut : ..........................................
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12.Apakah anda/keluarga pernah mendapatkan pelayanan di UGD Puskesmas
Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut: ...........................................
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13.Apakah anda/keluarga pernah mendapatkan pelayanan rawat inap di
Puskesmas Pleret?
a. Belum pernah
b. Sudah pernah. Pendapat anda mengenai pelayanan
tersebut: ...........................................
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14.Apakah anda pernah merasa khawatir akan tertular suatu penyakit saat
anda berada di Puskesmas Pleret?
a. Belum pernah

b. Sudah pernah. Apakah anda memiliki usulan /saran untuk mencegah

hal tersebut?
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15.Mohon memberikan kritik dan saran tentang segala sesuatu yang ada di
Puskesmas Pleret (sarana prasarana, pelayanan, SDM)
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