Section 1 of 5
PUSAT KELUHAN & SARAN PELAYANAN PUBLIK RUMAH SAKIT UMUM DAERAH KOMODO
Yth. Bapak/Ibu pengguna layanan RSUD Komodo. Terima kasih telah meluangkan waktu untuk mengisi formulir keluhan & saran pelanggan. Kami mohon maaf atas ketidaknyamanan yang
Bapak/Ibu alami.
Aventus jandu
Aventus jandu
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Alamat
Alamat
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Nomor HP
Nomor HP
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E-MAIL (jika ada)
E-MAIL (jika ada)
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Hari/Tanggal
Hari/Tanggal
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Waktu
Waktu
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Siapa Yang Mengalami Keluhan?
Siapa Yang Mengalami Keluhan?
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Saya sendiri
Keluarga saya
Kerabat saya
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Apakah Bapak/Ibu memiliki nomor
Rekam Medis (RM) ?
Apakah Bapak/Ibu memiliki nomor
Rekam Medis (RM) ?
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Ya
Tidak
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Status pembiayaan pasien
Status pembiayaan pasien
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BPJS
Asuransi Non BPJS
Umum
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Section 2 of 5
Keluhan
Bapak/Ibu Mengenai Pelayanan Petugas Non Medis
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Loket / Administrasi
Satpam (Keamanan)
Tenaga Kebersihan (CS)
Petugas Non Medis Lainnya
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Section 3 of 5
Keluhan Bapak/Ibu Mengenai Pelayanan Petugas Medis
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Dokter Spesialis
Dokter Umum
Dokter Gigi
Perawat
Bidan
Laboratorium
Apoteker
Radiografer
Fisioterapi
Ahli Gizi
Konselor
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Section 4 of 5
Keluhan Bapak/Ibu Mengenai Layanan
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Poli Umum
Poli Anak
Poli Bedah
Poli Penyakit Dalam
Poli Saraf
Poli Gigi
Poli Kebidanan
Rawat Inap
Kamar Operasi (OK)
IGD
ICU
NICU
VK
Nifas
Farmasi
Kamar jenazah
Fisioterapi
Radiologi
Poli Gizi
Layanan Lainnya (jawaban Bapak/Ibu)
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Section 5 of 5
Fasilitas
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Parkir
Taman
Ambulance
Toilet
Ruang Tunggu
Fasilitas Lainnya (jawaban Bapak/Ibu)
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Dimana keluhan tersebut terjadi?
Silahkan ditulis kronologis pada isian
berikut...
Dimana keluhan tersebut terjadi?
Silahkan ditulis kronologis pada isian
berikut...
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