PEMERINTAH KABUPATEN PACITAN

BADAN PENANGGULANGAN BENCANA DAERAH

Jl. Walanda Maramis No : 09 Pacitan 63514
Telp/Fax (0357) 886164, Website : bpbd.pacitankab.go.id
E-mail : bpbd_pacitan@yahoo.com & bpbd@pacitankab.go.id

LAPORAN HASIL
Pada Hari : …………………, Tanggal :……………, Bulan : ……………….…, Tahun : ……………….
Kegiatan : ………………………………………………………………………………………………….
Telah dilaksanakan kegiatan ………………………………………….........................................................
Dalam rangka………………………………………….……………………Di Dusun ……………………
Desa ………………………… Kecamatan Nawangan Kabupaten Pacitan, dengan hasil sebagai berikut :
A. Daftar Petugas
No Nama Jabatan Keterangan
1
2
3
4
5

B. Lembar Hasil Verifikasi Lapangan

Desa : ………………………..
Kecamatan : ………………………..
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Mengetahui : Fasilitator Lapangan/Koordinator :

1. ………………………….

2. …………………………
__________________________ 3. …………………………
C. CATATAN DATA PENDUKUNG

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