CHECK LIST PETUGAS KEBERSIHAN RUANGAN BULAN ......................... ........
TAHUN .................
PUSKESMAS MADUREJO
NO
URAIAN
1 M!"#!$%&'()* M!"#!$%&'()* +!#, 2 M!*-), M!*-), 3 M!*/!!0 M!*/!!0 4 M!"#,)*/ %)")' 5 M!*//)* ()**/ ()**/ 0)%( %)")' 6 M!$)&()* "!) +)* (,$%& (!$) (!$) 7 M!")()* 0)", -)*/ -)*/ +)( +&!$0,()* 8 M!*/,*& &*,&*, &*,&*, 9 M!$)&()* )0) )+) !")*-) !")*-) NAMA PETUGAS
PARAF PETUGAS 1
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CHECK LIST PETUGAS KEBERSIHAN RUANG DAPUR BULAN ......................... ........
TAHUN .................
PUSKESMAS MADUREJO
NO
URAIAN
1 M!"#!$%&'()* M!"#!$%&'()* +!#, 2 M!*-), M!*-), 3 M!*/!!0 M!*/!!0 4 M!"#,)*/ %)")' 5 M!*//)* ()**/ ()**/ 0)%( %)")' 6 M!$)&()* )0))0) )0))0) +),$ 7 M!*,& 0) %!) %), "&*//, %!()0& %!()0& 8 M!*//)* /)0* /)0* /,0) +)* !' -)*/ ')#&% 9 M!*-&")* )0) )+) !")*-) !")*-) NAMA PETUGAS
PARAF PETUGAS 1
2
3
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9 1 11 12 13 14
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16 17 18 19 2 21 22 23 24 25
26 27 28 29
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CHECK LIST PETUGAS KEBERSIHAN TOILET C : BULAN ......................... ........
TAHUN .................
PUSKESMAS MADUREJO
NO
URAIAN
1 M!*-&() M!*-&() +&*+&*/ (!$)"&( 2 M!*-&() M!*-&() 0)*)& &0! C : 3 M!*-&() M!*-&() (0%! 4 M!*/,$)% #)( )&$ 5 M!*/&%& #)( #)( )&$ 6 M!*//)* %)#,* %)#,* -)*/ ')#&% 7 M!"#!$& !;)*/& !;)*/& &0! 8 M!*//)* (!%! (!%! #&0) #)%)' 9 M!*!",$ (!%! 1 M!*/!"#)0&()* M!*/!"#)0&()* )0) )+) !")*-)
PARAF PETUGAS 1
2
3
4
5
6
7
8
9 1 11 12 13 14
15
16 17 18 19 2 21 22 23 24 25
26 27 28 29
3
31
