Form. PM. 10.

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

……………………………
Dibuat oleh,

waka / KPK

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

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

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

..................................................................................................................................................................
……. ………………………
Dilaksanakan oleh,

……………………………

7. Verifikasi hasil tindakan penanganan :

Sesuai Tidak Sesuai

Catatan (bila ada) ………..………………………

........................................................................... Diverifikasi oleh,
...........................................................................
...........................................................................
...........................................................................
........................................................................... Waka / KPK