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Formulir BOS-6A

LEMBAR PENCATATAN PENGADUAN MASYARAKAT

1. Identitas Pengadu
a. Nama : .................................................................................
b. Alamat : .................................................................................
.................................................................................

2. Tanggal Terima Pengaduan : ................................................................

3. Lokasi Kejadian
a. RT/R/Dusun : ...........................................................................
b. Desa/Kelurahan : ...........................................................................

. KPraobvui$nasit : ...........................................................................
en/Kota

&. Uraian Pengaduan :


...........................................................................................................
...........................................................................................................
........................................................................................................... (.

Tanggal Pen)elidikan Dilakukan ..................................................................

*. Pen)elidik ............................................................................................

+. Temuan
...........................................................................................................
...........................................................................................................

8. Ke$utusan/Rekomendasi :
...........................................................................................................
...........................................................................................................

9. Pelaksanaan Ke$utusan
...........................................................................................................
...........................................................................................................

1. Tanggal Pemberitahuan ke$ada Pengadu tentang ke$utusan/dan $elaksanaan ke$utusan


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

11. Dokumen )ang diterima :


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

..................................... 2 

0ela$orkan :
UP0 Prov/Kab/Kota/ekolah

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5/28/2018 Formulir BOS-6A (Pengaduan) - slidepdf.com

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