Download as docx, pdf, or txt
Download as docx, pdf, or txt
You are on page 1of 3

Program ///////////////////

Pekerjaan :
Konsultan Pengawas :
Kontraktor Pelaksana :

PERMINTAAN TINDAKAN PERBAIKAN


lembar 1 Kontraktor
Pemeriksa : ……………………………………….
lembar 2 Pengawas
Tanggal : ………………………………………. lembar 3 Arsip

1. KETIDAKSESUAIAN
RINCIAN




Dokumen acuan 


Prosedur acuan 

2. TINDAKAN PERBAIKAN & PENCEGAHAN


USULAN TINDAKAN PERBAIKAN




Diajukan pada (tanggal) : 


Diselesaikan pada (tanggal) : 
Konfirmasi Pelaksana Kegiatan/Pengelola Teknis Proyek : 

USULAN TINDAKAN PENCEGAHAN






Diajukan pada (tanggal) : 


Diselesaikan pada (tanggal) : 
Konfirmasi Pelaksana Kegiatan/Pengelola Teknis Proyek : 

3. TINDAK LANJUT

Oleh : 
Tanggal : 

Rincian




Oleh Tanda tangan / Tanggal Mengetahui

You might also like