Formulir BOS-6A (Pengaduan)

Formulir BOS-6A

LEMBAR PENCATATAN PENGADUAN MASYARAKAT

1. Identitas Identitas Pengadu Pengadu a. Nama : b. Alamat Alamat :

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2. Tanggal Tanggal Terima Pengaduan Pengaduan 3. Lokasi Lokasi Kejadian Kejadian a. RT/R/!usun RT/R/!usun b. !esa/Kelura" !esa/Kelura"an an #. Kabu$aten/Ko Kabu$aten/Kota ta d. Pro%insi Pro%insi

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&. 'raian 'raian Pengadua Pengaduan n: ........................................................................................................... ........................................................................................................... ........................................................................................................... (. Tanggal Pen)elidikan !ilakukan ......................................... ................................................... .................... ............... ..... *. Pen)elidik ................................................................................ ............................................................................................ ............ +. Temuan Temuan ........................................................................................................... ........................................................................................................... ,. Ke$utusan/Rek Ke$utusan/Rekomenda omendasi si : ........................................................................................................... ........................................................................................................... -. Pelaksanaan Pelaksanaan Ke$utusan Ke$utusan ........................................................................................................... ........................................................................................................... 1. Tanggal Tanggal Pemberita"ua Pemberita"uan n ke$ada Pengadu Pengadu tentang tentang ke$utusan/da ke$utusan/dan n $elaksanaa $elaksanaan n ke$utusan ............................................................................................. 11. !okumen !okumen )ang diterima diterima : ........................................................................................................... ........................................................................................................... ........................................................................................................... ........................................................................................................... ..................................... 2  0ela$orkan : 'P0 Pro%/Kab/Kota/ekola"

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