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    Pangkalan Kuras II
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    INSTRUMEN_PEROLEH_MASUKAN

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    Instrumen Peroleh Masukan

    Diunggah oleh

    Pangkalan Kuras II

    Hak Cipta:

    © All Rights Reserved
    Unduh sebagai DOCX, PDF, TXT atau baca online dari Scribd
    Tandai sebagai konten tidak pantas
    dari 1

    DINAS KESEHATAN KABUPATEN PELALAWAN DINAS KESEHATAN KABUPATEN PELALAWAN

    DINAS KESEHATAN KABUPATEN PELALAWAN BADAN LAYANAN UMUM DAERAH BADAN LAYANAN UMUM DAERAH
    BADAN LAYANAN UMUM DAERAH PUSKESMAS RAWAT INAP LANGGAM PUSKESMAS RAWAT INAP LANGGAM
    PUSKESMAS RAWAT INAP LANGGAM KECAMATAN LANGGAM KECAMATAN LANGGAM
    KECAMATAN LANGGAM JALAN SUDIRMAN NO. 2 LANGGAM 28381 JALAN SUDIRMAN NO. 2 LANGGAM 28381
    JALAN SUDIRMAN NO. 2 LANGGAM 28381

    KUESIONER USULAN KEGIATAN UKM KEGIATAN UKM KEGIATAN UKM

    NAMA : NAMA KEGIATAN : NAMA KEGIATAN :


    DESA/LOKASI : WAKTU : WAKTU :
    TEMPAT : TEMPAT :

    I. TANGGAPAN TERHADAP KEGIATAN (Baik / V. TANGGAPAN TERHADAP KEGIATAN (Baik / III. TANGGAPAN TERHADAP KEGIATAN (Baik /
    Tidak Baik, Puas / Kurang Puas / Tidak Puas, Atau Tidak Baik, Puas / Kurang Puas / Tidak Puas, Atau Tidak Baik, Puas / Kurang Puas / Tidak Puas, Atau
    Lainnya) Lainnya) Lainnya)

    1. .................................................................................. 7. .................................................................................. 4. ..................................................................................


    .................................................................................. .................................................................................. ..................................................................................
    .............................................................................. .............................................................................. ..............................................................................
    2. .................................................................................. 8. .................................................................................. 5. ..................................................................................
    .................................................................................. .................................................................................. ..................................................................................
    .............................................................................. .............................................................................. ..............................................................................
    3. .................................................................................. 9. .................................................................................. 6. ..................................................................................
    ................................................ ................................................ ................................................

    II. USULAN / MASUKAN / SARAN / KRITIK VI. USULAN / MASUKAN / SARAN / KRITIK IV. USULAN / MASUKAN / SARAN / KRITIK

    1. .................................................................................. 7. .................................................................................. 4. ..................................................................................


    ............................................................................... ............................................................................... ...............................................................................
    2. .................................................................................. 8. .................................................................................. 5. ..................................................................................
    .................................................................................. .................................................................................. ..................................................................................
    .............................................................................. .............................................................................. ..............................................................................
    3. .................................................................................. 9. .................................................................................. 6. ..................................................................................
    .................................................................................. .................................................................................. ..................................................................................
    ............................................................................. ............................................................................. .............................................................................

    TTD TTD TTD

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

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