No.Dokumen :
No. Revisi :
DAFTAR
TILIK
Tgl.Terbit :
Halaman :
UPTD Joko Budi HS.S.Kep.Ns.M.Si
PUSKESMAS NIP.19691105 199003 1 004
SAMBONG
KAB.BLORA
Unit : .....................................................................................................................
Nama Petugas : .....................................................................................................................
Tanggal Pelaksanaan : …………………………………………………………………….............
No Kegiatan Ya Tidak TB
Pelaksana/Auditor