LEMBAR UJI KELAYAKAN ALKES SEKALI PAKAI

NAMA ALAT : …………………………………… …………………..

NAMA PRODUSEN : …………………………………………………………
WAKTU UJICOBA : ………………………………………………………….
LOKASI UJI COBA : 1. ……………………………………………………… 6. …………………………………………………………..
2………………………………………………………. 7. ………………………………………………………….
3……………………………………………………….. 8. ………………………………………………………….
4……………………………………………………….. 9. …………………………………………………………..
5. …………………………………………………….. 10. ………………………………………………………..
Mengetahui
Bojonegoro, …………………….
Bagian Farmasi Ka. Instalasi …………….. Komite PPI

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PENILAIAN
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KESIMPULAN : O Direkomendasikan O Lain lain

O Tidak Direkomendasikan --------------------------------------------------------

Bojonegoro,
Yang Menyatakan,

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