Pada hari ini ............ tanggal ....... bulan ………….. tahun 2021 telah dilakukan Pemeriksaan
Kesehatan Lingkungan TFU (SD, SMP/ Sederajat (SD, SLB, MI, MDA, SMP, MTS, Pesantren))*,
Terhadap :
Nama TFU : .........................................................................................................
Nama Pimpinan : .........................................................................................................
Jumlah Murid/Santri : ..........................................................................................................
Rata-rata Kunjungan Puskesmas
Alamat : .........................................................................................................
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No.Telp/ HP : .........................................................................................................
Saran dan Rekomendasi :
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Hasil penilaian Inspeksi Kesehatan Lingkungan TFU (SD, SMP,/Sederajat (SD, SLB, MI, MDA, SMP,
MTS, Pesantren))*, mendapat total skore : ....... (............................................................................)
Demikian berita acara ini dibuat untuk dipergunakan sebagaimana mestinya.
..........................,........................ 2021
2. ................................................
NIP/Nr. PTT.
(..............................................)