Nomor: …(1)/YANMED-KEP/LKTPP/…(2:bulan)/2022
NAMA
NIP/NIK
PERIHAL
UNIT
HARI/TGL./BLN./TH.
JAM KEJADIAN/SHIFT
KETIDAKSESUAIAN/
KELUHAN
PEDOMAN
AKAR MASALAH
TINDAKAN PERBAIKAN
BATAS WAKTU
PENYELESAIAN
Selesai Tidak Selesai Paraf: Paraf:
TINDAKAN PENCEGAHAN
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Pembuat
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NIP/NIK