Halaman :
Pemerintah
drg. Sri Sutjiati
Kabupaten Puskesmas Leksono 1
NIP. 197011132002122007
Wonosobo
Tgl Mulai
No Isi Dokumen Isi Perubahan
Diberlakukan
Unit : ..................................................................................
Nama Petugas : ..................................................................................
Tgl. Pelaksanaan : ..................................................................................
……………………………..,…………..
Observer Tindakan
……………………………..............
NIP: …………………...................