DINAS KESEHATAN KOTA KEDIRI

UPTD PUSKESMAS PERAWATAN NGLETIH

JL. RAYA NGLETIH BAWANG NO.34 KM.2 KOTA KEDIRI

LEMBAR KOTAK SARAN

Silahkan dilingkari PELAYANAN KURANG PUAS di Poli/Unit:

1. Unit Pendaftaran 7. Unit Gizi
2. Unit Pelayan Umum 6. Unit Unit TB
3. Poli Gigi 7. Unit Remaja
4. Unit KIA-KB 8. Unit HIV-IMS
5. Unit Laboratorium 9. Unit Tata Usaha
6. Unit Apotik 10. Unit Rawat Inap
DALAM HAL
(jelaskan): ..................................................................................
......
....................................................................................................
...........................
Silahkan dilingkari KURANG PUAS dengan perilaku petugas
pelayanan:
1. Senyum
2. .
3. .
Oleh petugas (tulis nama petugas, bisa lebih dari satu
nama) .........................................................................................
....................................................................................................
.................................................................
SARAN :
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 DINAS KESEHATAN KOTA KEDIRI DINAS KESEHATAN KOTA KEDIRI
UPTD PUSKESMAS PERAWATAN NGLETIH UPTD PUSKESMAS PERAWATAN NGLETIH
JL. RAYA NGLETIH BAWANG NO.34 KM.2 KOTA KEDIRI JL. RAYA NGLETIH BAWANG NO.34 KM.2 KOTA KEDIRI

LEMBAR KOTAK SARAN LEMBAR KOTAK SARAN

Silahkan dilingkari PELAYANAN KURANG PUAS di Poli/Unit: Silahkan dilingkari PELAYANAN KURANG PUAS di Poli/Unit:
13. Unit Pendaftaran 7. Unit 7. Unit Pendaftaran 7. Unit Gizi
Gizi 8. Unit Pelayan Umum 6. Unit Unit TB
14. Unit Pelayan Umum 6. Unit 9. Poli Gigi 7. Unit Remaja
Unit TB 10. Unit KIA-KB 8. Unit HIV-IMS
15. Poli Gigi 7. Unit Remaja 11. Unit Laboratorium 9. Unit
16. Unit KIA-KB 8. Unit HIV-IMS Tata Usaha
17. Unit Laboratorium 9. Unit 12. Unit Apotik 10. Unit Rawat
Tata Usaha Inap
18. Unit Apotik 10. Unit Rawat DALAM HAL
Inap (jelaskan): ..................................................................................
DALAM HAL ......
(jelaskan): .................................................................................. ....................................................................................................
...... ...........................
.................................................................................................... Silahkan dilingkari KURANG PUAS dengan perilaku petugas
........................... pelayanan:
Silahkan dilingkari KURANG PUAS dengan perilaku petugas 4. Senyum
pelayanan: 5. .
7. Senyum 6. .
8. . Oleh petugas (tulis nama petugas, bisa lebih dari satu
9. . TANGGAL: .................... nama) .........................................................................................
TANGGAL: ....................
Oleh petugas (tulis nama petugas, bisa lebih .........dari satu ....................................................................................................
.........
NAMA PEMBERI SARAN:
nama) ......................................................................................... .................................................................NAMA PEMBERI SARAN:
.....................................
.................................................................................................... SARAN : .....................................
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ALAMAT: ....................... ALAMAT: .......................
SARAN : .........................................................................................................
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...................................................... No.HP: .......................... .........................................................................................................
No.HP: ..........................