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FORM REKOMENDASI SATUAN KERJA

1. Judul Penelitian :....................................................................................................................

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2. Data Penelitian

a. Nama Peneliti :....................................................................................................................

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b. No. Telepon/HP :....................................................................................................................

c. Alamat/email :....................................................................................................................

d. Institusi :...................................................................................................................

3. Periode Penelitian :....................................................................................................................

4. Subjek Penelitian :...................................................................................................................

5. Jumlah/Besar Sampel :...................................................................................................................

6. Lokasi Penelitian

a. Satuan Kerja :...................................................................................................................

b. Bangsal/Ruang :...................................................................................................................

7. Kesediaan : YA / TIDAK

a. Catatan :...................................................................................................................

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Palembang,
Mengetahui
Kepala Instalasi/Bagian/Ruang.......................................

Nama.............................................................................
NIP.................................................................................

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