RUMAH SAKIT MM INDRAMAYU

Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

RAHASIA
KOMITE ETIK DAN HUKUM
BERITA ACARA PEMERIKSAAN KEJADIAN PERKARA
Nomor : KERS/…../20/BAP-KP/…….

Tanya Jawab Terhadap Pihak Terkait atau saksi

pada hari ini, ……................ Tanggal ……................ bulan ……................ tahun ……................
Kami Selaku Anggota Komite Etik dan Hukum Rumah Sakit MM :
No Nama Jabatan Keahlian
1 Ir, Yudo Budi Santoso, SH Ketua Pemeriksa
2 Dwi Arifianto, AMd. Kep. Sekretaris Pemeriksa
3 Dr. Indra, S.Kep.,Ns., MPH Anggota Pemeriksa
4 Desy Lukita Ayu, SKM Anggota Pemeriksa

Berdasarkan wewenang yang ada pada kami, telah melakukan pemeriksaan terhadap:
Nama :
Jabatan :
Unit Kerja

Karena yang bersangkutan Terkait atau mengetahui dugaan terjadi pelanggaran etik dan atau disiplin
karyawan dengan temuan atau adanya pengaduan dan alat bukti :
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 RUMAH SAKIT MM INDRAMAYU
Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

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Saya telah melakukan tanya jawab kepada yang bersangkutan dengan rincian sebagai berikut :

1. Pertanyaan : Sebut kan,

1.Nama :
2.Jabatan :
3. Alamat Rumah :
4.Contak Person :
Jawaban :
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2. Pertanyaan :
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Jawaban :
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3. Pertanyaan :
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Jawaban :
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4. Pertanyaan :
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Jawaban :
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5. Pertanyaan :
 RUMAH SAKIT MM INDRAMAYU
Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

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Jawaban :
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6. Pertanyaan :
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Jawaban :
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7. Pertanyaan :
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Jawaban :
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8. Pertanyaan :
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Jawaban :
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9. Pertanyaan :
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Jawaban :
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 RUMAH SAKIT MM INDRAMAYU
Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

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10. Pertanyaan :
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Jawaban :
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11. Pertanyaan :
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Jawaban :
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12. Pertanyaan :
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Jawaban :
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13. Pertanyaan :
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Jawaban :
 RUMAH SAKIT MM INDRAMAYU
Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

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14. Pertanyaan :
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Jawaban :
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15. Pertanyaan :
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Jawaban :
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16. Pertanyaan :
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Jawaban :
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17. Pertanyaan :
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Jawaban :
 RUMAH SAKIT MM INDRAMAYU
Jl. Letjend. Soeprapto No. 292 Kepandean Indramayu – Jawa Barat 45214
Email: rumahsakit.mm@gmail.com Telp: (0234) 277632/ 33/ 34 PT. BHARATI PUTRI MANDIRI

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Demikian Berita Acara Pemeriksaan awal ini dibuat dengan penuh kesungguhan untuk dapat
digunakan sebagimana mestinya.

Yang Diperiksa, Pemeriksa,

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