Nomor : 011.

/FM TINDAKAN PERBAIKAN

DAN PENCEGAHAN
Revisi ke :
Berlaku Tgl. : JANUARI 2017 FORMULIR
No. Dokumen FM/................./WMM/2017
Revisi Ke
Tanggal berlaku
KABUPATEN UPTD
BOJONEGORO
TINDAKAN PERBAIKAN & PENCEGAHAN PUSKESMAS SEKAR

No. Permohonan :
Bagian/Urusan/Unit :
Tgl. :
Temuan oleh Karyawan / Unit Keluhan Pelanggan

Audit Internal Lain-lain

Uraian Keluhan/ Pengaduan;
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
(disi oleh pelapor)
Pelapor Penerima Tanggal

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

Tindakan Perbaikan & Pencegahan;

.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
.................................................................................................................................................................
(Diisi oleh Manajemen Mutu)
Batas Tanggal Penyelesaian Penanggung jawab Tindakan
Tindakan Perbaikan & Perbaikan & PJ Unit
Pencegahan Pencegahan

(.........................................) (.........................................)
Verifikasi Tindakan Perbaikan & Pencegahan : Tanggal Verifikasi
.......................................
Wakil Manajemen Mutu

(.........................................)