DINAS KESEHATAN
UPTD KESEHATAN PUSKESMAS
Bulan :
TANGGAL
NO JENIS KEGIATAN KET
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
1 Listrik/Genset
2 Air
3 Ventilasi/AC
4 IPAL
5 Gas
Paraf
Petugas/pekerja
Paraf Petugas
Sanitarian
Keterangan : √ = Cek selesai bersih, berfungsi baik
— = Cek selesai blm bersih/belum berfungsi baik
Mengetahui Pasuruan,
Kepala UPTD Kesehatan Petugas Sanitarian
Puskesmas
…………………………… ……………………………..
NIP. NIP.
Catatan Keluhan
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