Anda di halaman 1dari 1

PEMERINTAH KABUPATEN NGAWI

RUMAH SAKIT UMUM DAERAH Dr. SOEROTO


Jl. Dr. Wahidin No. 27 Ngawi Telp (0351) 749023
Fax : (0351) 744774

FORMAT IDENTIFIKASI MASALAH ETIK DAN DISIPLIN PERAWAT


Nama Pengidentifikasi : ......................................................................
NIP : …………………………………………………..
Pangkat/ Gol : …………………………………………………..
Unit Kerja : ......................................................................
Jabatan : ......................................................................

A. Deskripsi Masalah Etik dan Disiplin


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

B. Unsur/ Individu yang Terlibat

No. Nama Jabatan Hak/ Kewajiban


1.
2.
3..

Ngawi, ________________
Pengidentifikasi

_______________________

Anda mungkin juga menyukai