Tata Naskah Daftar Tilik Fix [PDF]

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Lampiran 9. Daftar Tilik SOP



MONITORING KEPATUHAN TERHADAP SOP MENJALIN KOMUNIKASI DENGAN MASYARAKAT No.



:



Dokumen DAFTAR TILIK



001/PKM/SOP/ADME N/II/2018



No. Revisi



:



00



Tanggal



:



14/02/2018



:



1/3



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Terbit Halaman UPT PUSKESMAS KECAMATAN JAWILAN



H. YASMAN, SKM. NIP.19600206 1983021 004



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Unit



: .......................................................................



Nama Pegawai



: .......................................................................



Tanggal Pelaksanaan



: .......................................................................



No



Langkah Kegiatan



Ya



1



Apakah petugas menerapkan budaya 3 S?



2



........................................................................?



3



......................................................................?



4



.....................................................................?



5



.........................................................................?



6



......................................................................?



7



.......................................................................? Jumlah



Compliance rate (CR) : ...................% Cara penghitungan :



∑Ya ∑Langkah



X 100% = ......%



Tidak



√ √ √ √ √ √ √



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Keterangan/Alasan : Langkah 2 : Lupa Langkah 4 : Blanko habis Langkah 6 : .................. Kesimpulan dan RTL : 1. ............................................................................... 2. ............................................................................... 3. ............................................................................... Serang,..........................201...



Enter 3 kali



Petugas yang dimonitoring



Tim Monitoring



(Tanda tangan)



1. Nama.......... (Tanda tangan)



(Nama Jelas)



2. Nama.......... (Tanda tangan)



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



3. dst.......................................



Isi menggunakan size 12 Spasi 1.5 Margin kiri/kanan: 3 cm Margin atas/bawah: 2.5 cm Kertas A4