Size

10 Size
13
Lampiran 9. Daftar Tilik SOP
MONITORING KEPATUHAN
TERHADAP SOP MENJALIN
KOMUNIKASI DENGAN MASYARAKAT
No. : 001/PKM/SOP/ADME
Dokumen N/II/2018

DAFTAR No. Revisi : 00 Size

TILIK Tanggal 10
: 14/02/2018
Terbit
Halaman : 1/3

UPT PUSKESMAS H. YASMAN,

KECAMATAN Size SKM. Size
JAWILAN 10 NIP.19600206 10
1983021 004

Unit : .......................................................................

Nama Pegawai : .......................................................................

Tanggal Pelaksanaan : .......................................................................

No Langkah Kegiatan Ya Tidak

1 Apakah petugas menerapkan budaya 3 S? √
2 ........................................................................? √
3 ......................................................................? √
4 .....................................................................? √
5 .........................................................................? √
6 ......................................................................? √
7 .......................................................................? √
Jumlah

Compliance rate (CR) : ...................%

Cara penghitungan : ∑Ya X 100% = ......%
∑Langkah
 Keterangan/Alasan :
Langkah 2 : Lupa
Langkah 4 : Blanko habis
Langkah 6 : ..................
Kesimpulan dan RTL :
1. ...............................................................................
2. ...............................................................................
3. ...............................................................................

Serang,..........................201...

Petugas yang dimonitoring Tim Monitoring

Enter 3 kali
(Tanda tangan) 1. Nama.......... (Tanda tangan)
(Nama Jelas) 2. Nama.......... (Tanda tangan)
......................................... 3. dst.......................................

Isi menggunakan size 12

Spasi 1.5
Margin kiri/kanan: 3 cm
Margin atas/bawah: 2.5 cm
Kertas A4