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    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI

    KARTU KEPUASAN PASIEN KARTU KEPUASAN PASIEN


    APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ? APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ?

    PUAS TIDAK PUAS DI POLI : TIDAK PUAS DI POLI :


    ALASAN : ....................................... ALASAN : .......................................
    TIDAK ...................................................... ......................................................
    PUAS ...................................................... ......................................................
    ............... ...............

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    KARTU KEPUASAN PASIEN KARTU KEPUASAN PASIEN
    APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ? APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ?

    TIDAK PUAS DI POLI : TIDAK PUAS DI POLI :


    ALASAN : ....................................... ALASAN : .......................................
    ...................................................... ......................................................
    ...................................................... ......................................................
    ............... ...............

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    KARTU KEPUASAN PASIEN KARTU KEPUASAN PASIEN
    APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ? APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ?

    TIDAK PUAS DI POLI : TIDAK PUAS DI POLI :


    ALASAN : ....................................... ALASAN : .......................................
    ...................................................... ......................................................
    ...................................................... ......................................................
    ............... ...............

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    KARTU KEPUASAN PASIEN KARTU KEPUASAN PASIEN
    APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ? APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ?

    TIDAK PUAS DI POLI : TIDAK PUAS DI POLI :


    ALASAN : ....................................... ALASAN : .......................................
    ...................................................... ......................................................
    ...................................................... ......................................................
    ............... ...............

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    KARTU KEPUASAN PASIEN KARTU KEPUASAN PASIEN
    APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ? APAKAH ANDA PUAS DENGAN PELAYANAN KAMI ?

    TIDAK PUAS DI POLI : TIDAK PUAS DI POLI :


    ALASAN : ....................................... ALASAN : .......................................
    ...................................................... ......................................................
    ...................................................... ......................................................
    ............... ...............
    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI
    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472

    PUSKESMAS PANDANWANGI
    \RU
    PUSKESMAS PANDANWANGI
    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472
    LEMBAR KELUHAN PELANGGAN/PASIEN LEMBAR KELUHAN PELANGGAN/PASIEN

    Tanggal
    SURVEY : KEPUASAN, SARAN DAN KELUHAN Tanggal
    SURVEY : KEPUASAN, SARAN DAN KELUHAN
    PELANGGAN UKM PELANGGAN UKM
    KELUHAN
    Tanggal : KELUHAN
    Tanggal :
    .....................................................................................
    Puaskah Anda dengan kegiatan pelayanan yang kami .....................................................................................
    Puaskah Anda dengan kegiatan pelayanan yang kami
    .....................................................................................
    berikan ? (Centang salah satu) .....................................................................................
    berikan ? (Centang salah satu)
    ..................................................................................... .....................................................................................
    .....................................................................................
    PUAS TIDAK PUAS .....................................................................................
    PUAS TIDAK PUAS
    ................................................................................ ................................................................................
    SARAN SARAN
    .....................................................................................
    KELUHAN .....................................................................................
    KELUHAN
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    ................................................................................
    SARAN ................................................................................
    SARAN
    NAMA :
    ..................................................................................... NAMA :
    .....................................................................................
    ALAMAT :
    ..................................................................................... ALAMAT :
    .....................................................................................
    NO. TELEPON :
    ..................................................................................... NO. TELEPON :
    .....................................................................................
    NAMA : NAMA :
    ALAMAT : ALAMAT :

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472
    LEMBAR KELUHAN PELANGGAN/PASIEN LEMBAR KELUHAN PELANGGAN/PASIEN

    Tanggal
    SURVEY : KEPUASAN, SARAN DAN KELUHAN Tanggal
    SURVEY : KEPUASAN, SARAN DAN KELUHAN
    PELANGGAN UKM PELANGGAN UKM
    KELUHAN
    Tanggal : KELUHAN
    Tanggal :
    .....................................................................................
    Puaskah Anda dengan kegiatan pelayanan yang kami .....................................................................................
    Puaskah Anda dengan kegiatan pelayanan yang kami
    .....................................................................................
    berikan ? (Centang salah satu) .....................................................................................
    berikan ? (Centang salah satu)
    ..................................................................................... .....................................................................................
    .....................................................................................
    PUAS TIDAK PUAS .....................................................................................
    PUAS TIDAK PUAS
    ................................................................................ ................................................................................
    SARAN SARAN
    .....................................................................................
    KELUHAN .....................................................................................
    KELUHAN
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    .....................................................................................
    ..................................................................................... .....................................................................................
    .....................................................................................
    ................................................................................
    SARAN ................................................................................
    SARAN
    NAMA :
    ..................................................................................... NAMA :
    .....................................................................................
    ALAMAT :
    ..................................................................................... ALAMAT :
    .....................................................................................
    NO. TELEPON :
    ..................................................................................... NO. TELEPON :
    .....................................................................................
    NAMA : NAMA :
    ALAMAT : ALAMAT :
    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI
    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472

    LEMBAR SARAN DAN KELUHAN LEMBAR SARAN DAN KELUHAN


    Tanggal : Tanggal :
    KELUHAN KELUHAN
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ....................................................................... .......................................................................
    SARAN SARAN
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ........................................................................ ........................................................................
    NAMA : NAMA :
    ALAMAT : ALAMAT :
    NO. TELP : NO. TELP :

    PUSKESMAS PANDANWANGI PUSKESMAS PANDANWANGI


    JL. LA Sucipto 315 Malang Telp. (0341) 484472 JL. LA Sucipto 315 Malang Telp. (0341) 484472

    LEMBAR SARAN DAN KELUHAN LEMBAR SARAN DAN KELUHAN


    Tanggal : Tanggal :
    KELUHAN KELUHAN
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ....................................................................... .......................................................................
    SARAN SARAN
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ..................................................................................... .....................................................................................
    ........................................................................ ........................................................................
    NAMA : NAMA :
    ALAMAT : ALAMAT :
    NO. TELP : NO. TELP :

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