PEMERINTAH KOTA SURABAYA

DINAS KESEHATAN
UPTD PUSKESMAS
KEDURUS
JlMastrip No 46 Kedurus - Surabaya
Telp. (031) 7663237

LAPORAN HASIL KEGIATAN

I. DASAR : ......................................................
II. NAMA PETUGAS : ......................................................
III.NAMA KEGIATAN : ......................................................
IV. PELAKSANAAN KEGIATAN : ......................................................
a. Rencana dan Realisasi
RENCANA REALISASI
KETERANGAN
WAKTU TEMPAT SASARAN WAKTU TEMPAT SASARAN

b. Tahapan Pelaksanaan
NO KEGIATAN/TAHAPAN REALISASI KETERANGAN

c. Masalah : ............................ Solusi : ................

d. Hambatan : ............................ Solusi : ................

e. Masukan/Umpan Balik
Masukan : ............................ Solusi : ................

e-mail. pkmkedurus@gmail.com
 f. Keluhan : ............................ Solusi : ................

g. Peran Lintas Sektor dan Lintas Program

Nama LP/LS Peran
................. .................. ...................

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

h. Kejelasan Informasi :
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i. Evaluasi :
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Surabaya, ............................
Mengetahui
Yang Bertanggung Jawab Petugas Pelaksana

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e-mail. pkmkedurus@gmail.com