PEMERINTAH KOTA BANDA ACEH

RUMAH SAKIT UMUM DAERAH MEURAXA

Jl. Soekarno-Hatta, Banda Raya, Banda Aceh (23238)
Telp./Faks. (0651) 43097/43095 Email : rsum@bandaacehkota.go.id
Website : http://rsum.bandaacehkota.go.id

FORMULIR PENGADUAN MASYARAKAT

NO : .................................................

Tempat : Pusat Informasi & Layanan Keluhan

Nama : ........................................................................................................
Alamat : ........................................................................................................
........................................................................................................
........................................................................................................
No. Peserta : .......................................................................................................
Waktu Penyampaian : ........................................................................................................
Nomor Telepon : ........................................................................................................
Pekerjaan : ........................................................................................................
Hal yang diadukan :
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
............................................................................................................
Poli/Ruangan/Dokter/Perawat/Petugas yang diadukan :
............................................................................................................
............................................................................................................
Waktu Penyelesaian :
...........................................................................................................
Keikutsertaan Keluarga/Pasien dalam Penyelesaian Masalah :
...........................................................................................................
...........................................................................................................
...........................................................................................................

Banda Aceh, ......................20..

Pengadu,

(.................................................)

0061/Rev01/IMR/2019