Section 1 of 1
Pelepasan Informasi Rekam Medis
Email
Email
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Tanggal Informasi Diterima
Tanggal Informasi Diterima
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Nama Penerima / Pemohon Informasi
Nama Penerima / Pemohon Informasi
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Alamat
Alamat
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
No HP / WA
No HP / WA
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Hubungan dengan Pasien / Pemilik Asuransi
Hubungan dengan Pasien / Pemilik Asuransi
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
1.
Suami
2.
Istri
3.
Orang tua
4.
Anak
5.
Saudara
6.
Diri Sendiri
7.
Lainnya
8.
Add option
…
Answer key
(0 points)
Loading...
No Rekam Medis Pasien
No Rekam Medis Pasien
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Nama Pasien / Pemilik Asuransi
Nama Pasien / Pemilik Asuransi
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Answer key
(0 points)
Loading...
Jenis Asuransi
Jenis Asuransi
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Taspen
Allianz
Sinar Mas
BNI Life
BRI Life
Other:
Add option
…
Answer key
(0 points)
Loading...
Informasi yang dibutuhkan
Informasi yang dibutuhkan
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Surat Keterangan Asuransi
Resume
Surat Keterangan Kematian
Surat Keterangan Kelahiran
Visum Et Repertum
Other:
Add option
…
Answer key
(0 points)
Loading...
Foto KTP/KK Penerima Informasi
Foto KTP/KK Penerima Informasi
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Add file
View folder
Allow only specific file types
Maximum number of files
1
5
10
Maximum file size
1 MB
10 MB
100 MB
1 GB
10 GB
View folder
Answer key
(0 points)
Loading...
Petugas Rekam Medis
Petugas Rekam Medis
Question Type
Short answer
Paragraph
Multiple choice
Checkboxes
Dropdown
File upload
Linear scale
Rating
Multiple choice grid
Checkbox grid
Date
Time
Trioda
Oktaviana
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Link to Sheets
Summary
Question
Individual
Insights
Total points distribution
Loading...
Settings
Responses
Manage how responses are collected and protected
Presentation
Manage how the form and responses are presented
Defaults
Form defaults
Settings applied to this form and new forms
Question defaults
Settings applied to all new questions