011 - Form Tindakan Perbaikan & Pencegahan [PDF]

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Nomor



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Revisi ke : Berlaku Tgl. :



011./FM TINDAKAN PERBAIKAN DAN PENCEGAHAN JANUARI 2017 No. Dokumen



FORMULIR FM/................./WMM/2017



Revisi Ke Tanggal berlaku KABUPATEN BOJONEGORO



No. Permohonan Bagian/Urusan/Unit Tgl.



TINDAKAN PERBAIKAN & PENCEGAHAN : : : Temuan oleh Karyawan / Unit



UPTD PUSKESMAS SEKAR



Keluhan Pelanggan



Audit Internal Lain-lain Uraian Keluhan/ Pengaduan; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (disi oleh pelapor) Pelapor Penerima Tanggal .....................................



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Analisa Penyebab Masalah; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (Diisi oleh Pengelola Unit/Auditor)



Tindakan Perbaikan & Pencegahan; ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. ................................................................................................................................................................. (Diisi oleh Manajemen Mutu)



Batas Tanggal Penyelesaian Tindakan Perbaikan & Pencegahan



Penanggung jawab Tindakan Perbaikan & Pencegahan



PJ Unit



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Verifikasi Tindakan Perbaikan & Pencegahan :



Tanggal Verifikasi ....................................... Wakil Manajemen Mutu



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