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UPTD
PUSKESMAS
PATARUMAN 1
Ika Rika Rohantika
NIP.197201022006042033
Unit : ................................................................................................................
Nama Petugas : ................................................................................................................
Tanggal Pelaksana :
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Jawaban
No Pertanyaan
Ya Tidak
1 Apakah petugas melakukan pengisian form PAR-Q sebelum
melakukan kegiatan ?
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Pelaksana / Auditor
( ................................................ )