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PEMERINTAH KOTA PEMATANGSIANTAR

DINAS KESEHATAN
UPTD PUSKESMAS RAMI
Jalan Medan Simpang Kerang KM. 4,5 Pematangsiantar 21137
Email : puskesmas.ramisiantar@gmail.com

FORMULIR MONITORING EVALUASI KEGIATAN DAN PERBAIKAN
KINERJA

UKP :-----------------------------

BULAN :-----------------------------

KEGIATAN YANG DILAKSANAKAN

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PENCAPAIAN SASARAN MUTU DAN KINERJA

TARGET/INDIKATOR KINERJA : ----------------------------------------------------------------------

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REALISASI : ---------------------------------------------------------------------------------------------

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-------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- KESIMPULAN TERCAPAI / TIDAK ANALISA / PENGHAMBAT PENCAPAIAN -------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- RENCANA TINDAK LANJUT -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- .

TINDAK LANJUT -------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- EVALUASI TINDAK LANJUT -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------------------- Mengetahui Penanggung jawab Pelaksana Lidia Riama Simanjuntak Sri Ike R Nainggolan NIP 19850402 201705 2 001 NIP 19820821 201001 2 017 .