5/28/2018 For mulir BOS-6A (Pe nga dua n) - slide pdf.c om

Formulir BOS-6A

LEMBAR PENCATATAN PENGADUAN MASYARAKAT

1. Identitas Pengadu
a. Nama : .................................................................................
b. Alamat : .................................................................................
.................................................................................

2. Tanggal Terima Pengaduan : ................................................................

3. Lokasi Kejadian
a. RT/R/!usun : ...........................................................................
b. !esa/Kelura"an : ...........................................................................

#.
d. Kabu$aten/Kota
Pro%insi :: ...........................................................................
...........................................................................

&. 'raian Pengaduan :

...........................................................................................................
...........................................................................................................
...........................................................................................................

(. Tanggal Pen)elidikan !ilakukan ..................................................................

*. Pen)elidik ............................................................................................

+. Temuan
...........................................................................................................
...........................................................................................................

,. Ke$utusan/Rekomendasi :
...........................................................................................................
...........................................................................................................

-. Pelaksanaan Ke$utusan
...........................................................................................................
...........................................................................................................

1. Tanggal Pemberita"uan ke$ada Pengadu tentang ke$utusan/dan $elaksanaan

ke$utusan .............................................................................................

11. !okumen )ang diterima :

...........................................................................................................
...........................................................................................................
...........................................................................................................
...........................................................................................................

..................................... 2 

0ela$orkan :
'P0 Pro%/Kab/Kota/ekola"

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5/28/2018 For mulir BOS-6A (Pe nga dua n) - slide pdf.c om

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