14.1 Cover Laporan Surveior.doc

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CETAK

KOMISI AKREDITASI FASILITAS KESEHATAN TINGKAT PERTAMA (File A)

(Saran : gunakan program Antivirus)

Puskesmas/FKTP

:

Alamat

: gal Survei

:

Tanggal Survei : Surveior

:

1. 2. 3. 4. 5.

Sekretariat Komisi Akreditasi Fasilitas Kesehatan Tingkat Pertama Telepon:................................ Fax: ........................ Web : ..........................

CETAK Identitas Surveior

NO.

NAMA SURVEIOR

JABATAN SURVEIOR

NO. DAN TANGGAL SURAT TUGAS

TANGGAL SURVEI

1 2 3 4 5

TIM SURVEI : Nama Ketua

:

Anggota

:

Tandatangan

……………………………..

(

………..………… )

1. …………………………

( ……………………. )

2. …………………………

( …………………… )

3. …………………………

( …………………… )

4. …………………………

( …………………… )

KETERANGAN

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