PELAKSANA KEBERSIHAN
Tanggal
Unit / Ruang rawat
Tanggal
Unit / Ruang rawat
: .....................................
: .....................................
Kegiatan Kebersihan
Puas
Penilaian
Tidak Puas
Angka
Lantai
Jendela & Dinding
Kamar mandi & Wastafel
Langit-langit
Tempat Sampah
Pemakaian Alat Pelindung Diri
(APD) dan Keterampilan Petugas
Stand by ruangan
Sopan Santun & kerapihan
penampilan
Kegiatan Kebersihan
Puas
Penilaian
Tidak Puas
Angka
Lantai
Jendela & Dinding
Kamar mandi & Wastafel
Langit-langit
Tempat Sampah
Pemakaian Alat Pelindung Diri
(APD) dan Keterampilan Petugas
Stand by ruangan
Sopan Santun & kerapihan
penampilan
*) dicentang saja ()
*) dicentang saja ()
Masukan / Saran :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
NB: Kriteria Penilaian
Puas
: 80 (diatas).
Cukup
: 60 (diatas).
Tidak Puas
: <60 (dibawah).
: .....................................
: .....................................
(...........................................
Masukan / Saran :
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
...................................................................................................................................
NB: Kriteria Penilaian
Puas
: 80 (diatas).
Cukup
: 60 (diatas).
Tidak Puas
: <60 (dibawah).
(...........................................