Judul Kegiatan :
Tanggal :
Nama Responden :
Dalam upaya meningkatkan Mutu dan Kualitas Pelayanan Puskesmas menjadi lebih baik, Kami
sangat mengharapkan Bapak/ Ibu berkenan memberikan kritik, saran serta harapan Anda kepada
Kami tentang kegiatan ini !
Kritik : ......................................................................................................................................................
..................................................................................................................................................
Saran : ......................................................................................................................................................
..................................................................................................................................................
Harapan : .................................................................................................................................................
......................................................................................................................................................
Tanggal :
Nama Responden :
Dalam upaya meningkatkan Mutu dan Kualitas Pelayanan Puskesmas menjadi lebih baik, Kami
sangat mengharapkan Bapak/ Ibu berkenan memberikan kritik, saran serta harapan Anda kepada
Kami tentang kegiatan ini !
Kritik : ......................................................................................................................................................
..................................................................................................................................................
Saran : ......................................................................................................................................................
..................................................................................................................................................
Harapan : .....................................................................................................................................
....................................................................................................................................................
...............