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LEMBAR LAPORAN HARIAN - SUPERVISOR

Tgl/bln/thn: ......................................................... Kabupaten/Kota: ........................................................

Nama/ Tanda Tangan Supersior Nama/ Tanda Tangan Koordinator

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CATATAN BRIEFING

Nama/ Tanda Tangan Nama/ Tanda Tangan Nama/ Tanda Tangan Nama/ Tanda Tangan
Enumerator 1 Enumerator 2 Enumerator 3 Enumerator 4

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Wilayah/ Target Wilayah/ Hasil Wilayah/ Target Wilayah/ Hasil Wilayah/ Target Wilayah/ Hasil Wilayah/ Target Wilayah/ Hasil
Enumerator 1 Enumerator 1 Enumerator 2 Enumerator 2 Enumerator 3 Enumerator 3 Enumerator 4 Enumerator 4

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Check list kegiatan


No Check items (v)
1 Briefing kuesioner (khusus hari 1)
Check kelengkapan
2 Pulpen
3 Pensil
4 Penghapus
Kuesioner
5a Kelengkapan halaman
5b Nomor kuesioner
7 Janji waktu dan tempat debriefing

CATATAN DEBRIEFING

Nama/ Tanda Tangan Nama/ Tanda Tangan Nama/ Tanda Tangan Nama/ Tanda Tangan
Enumerator 1 Enumerator 2 Enumerator 3 Enumerator 4

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CATATAN (HAL YG MEMPERLANCAR & KESULITAN2 YANG DIHADAPI & RENCANA SOLUSI)
1. .......................................................................................................................................
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4. .......................................................................................................................................
LEMBAR LAPORAN REKAP HARIAN – SUPERVISIOR
SURVAI PENILAIAN RISIKO KESEHATAN LINGKUNGAN

Tanggal: Wilayah:

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Nama/ Tanda Tangan Supervisior

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JUMLAH KUESIONER TERKUMPUL

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JUMLAH KUESIONER TOTAL YANG TERKUMPUL


(AKUMULASI)

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