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FORMULIR PERBAIKAN SARANA DAN PRASARANA

RUMAH SAKIT ISLAM ‘AISYIYAH NGANJUK

Tanggal :.......................................................................................
Nama Pelapor :.......................................................................................
Instalasi / unit :.......................................................................................
Uraian Laporan

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Tindakan

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Penggantian sparepart
Nama Jumlah

Selesai
Belum selesai
Hasil Akhir
Menunggu sparepart
Pihak Ke 3

Pelapor / penanggung jawab ruang Mengetahui Pelaksana Perbaikan


Ka.Subag Rumah Tangga

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