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PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
PUSKESMAS PANTI
JL. PB. SUDIRMAN NO. 85 PANTI JEMBER

LEMBAR UMPAN BALIK

NAMA : ........................... TGL : ...........................

NO. HP : ...........................

APAKAH ANDA PUAS DENGAN PELAYANAN KAMI?


a. IYA
b. TIDAK

JIKA TIDAK PUAS, MOHON TULISKAN KRITIK SARAN DAN MASUKAN UNTUK KAMI
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
TERIMA KASIH.
TTD

PEMERINTAH KABUPATEN JEMBER


DINAS KESEHATAN
PUSKESMAS PANTI
JL. PB. SUDIRMAN NO. 85 PANTI JEMBER

LEMBAR UMPAN BALIK

NAMA : ........................... TGL : ...........................

NO. HP : ...........................

APAKAH ANDA PUAS DENGAN PELAYANAN KAMI?


a. IYA
b. TIDAK

JIKA TIDAK PUAS, MOHON TULISKAN KRITIK SARAN DAN MASUKAN UNTUK KAMI
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
TERIMA KASIH.
TTD

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