LAPORAN HASIL KEGIATAN

1. Tanggal Kegiatan :
2. Nama Kegiatan :
3. Tempat Kegiatan :
4. Sasaran :

a. Hasil Kegiatan
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b. Indikator Keberhasilan
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c. Kesenjangan/masalah
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d. Upaya Pemecahan Masalah

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e. Lain-lain :
1). Peran Lintas Program
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2). Peran Lintas Sektor (bila ada)

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Mengetahui Lintas Sektor :

Nama : .................................................... ................................

Mengetahui,
Penanggung Jawab ............... Pelaksana
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