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Form. PM. 8.3.

1/L1
Rev. 0
LAPORAN KETIDAKSESUAIAN
1. Kepada : ..............................................................................................................................................
2. Dari :
3. Uraian ketidaksesuaian produk/pelayanan : ............................................................................................
..................................................................................................................................................................
..................................................................................................................................................................
4. Mohon dianalisis dan ditindaklanjuti paling lambat tanggal .....................................................................

Ajibarang, ...................................
Dibuat oleh,

Puja Leksana, SS
Ka.Bidang Kesiswaan

5. Sebab-sebab masalah : .........................................................................................................................


..................................................................................................................................................................

6. Tindakan penanganan yang dilakukan : ..................................................................................................


..................................................................................................................................................................
Ajibarang, .........................
Dilaksanakan oleh,

Puja Leksana, SS
Ka. Bidang Kesiswaan

7. Verifikasi hasil tindakan penanganan :


Sesuai Tidak Sesuai

Catatan (bila ada) Ajibarang, .........................


........................................................................... Diverifikasi oleh,
...........................................................................
...........................................................................
........................................................................... Puja Leksana, SS
........................................................................... Ka. Bidang Kesiswaan

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