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BERITA ACARA

INSPEKSI KESEHATAN LINGKUNGAN


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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 : .........................................................................................................
.........................................................................................................
No.Telp/ HP : .........................................................................................................
Saran dan Rekomendasi :
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

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

Mengetahui, Tim Pemeriksa


Pimpinana Sekolah 1. ................................................
NIP/NRPK.

2. ................................................
NIP/Nr. PTT.
(..............................................)

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