LEMBAR EVALUASI PELAKSANAAN KOMITMEN DAERAH

1. Jenis Penugasan : Penugasan Khusus Berbasis Tim/Penugasan Khusus Individu *

2. Nama : ..................................................................................................

3. Jenis tenaga : ..................................................................................................

4. Batch/periode : ..................................................................................................

5. Puskesmas : ..................................................................................................

6. Kabupaten : ..................................................................................................

7. Provinsi : ..................................................................................................

8. Jumlah NS di puskesmas : ......... orang

9. Apakah disediakan tempat tinggal? : ......................................................................

10. Kapasitas tempat tinggal : ......... orang

11. Status rumah tinggal : disediakan/kontrak dengan membayar sendiri*

Lain-lain : .....................................................................................

12. Kondisi rumah tinggal : ......................................................................................

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13. Jarak tempat tinggal ke puskesmas : ......................................................................

14. Ketersediaan sarana/prasarana/alat kesehatan pendukung kerja : ........................

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15. Fasilitas/dukungan lain yang diberikan oleh Pemda: ...............................................

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16. Kendala yang dihadapi: ...........................................................................................

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Keterangan:
*Coret salah satu
............................., ........ Januari 2018
Peserta

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