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Pengaduan Masyarakat
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Nama Lengkap
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NIK / Nomor Identitas
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Jenis Kelamin
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Laki-laki
Perempuan
Usia
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Pekerjaan
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Alamat Lengkap
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Nomor Telepon/HP
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Email (jika ada)
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Jenis Permasalahan (pilih salah satu atau lebih)
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Pendidikan (sekolah, guru, siswa, fasilitas, dll)
Kebudayaan (pelestarian budaya, seni, kegiatan adat, dll)
Administrasi/Layanan Publik
Keuangan/BOS/Beasiswa
Lainnya
Judul/Materi Pengaduan
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Uraian Singkat Permasalahan
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Lokasi Kejadian
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Nama Sekolah/Unit/Tempat
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Kecamatan/Kabupaten
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Waktu Kejadian (Hari,Tanggal, Jam)
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Pihak yang Terlibat (jika ada)
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Keterangan
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Tindak Lanjut yang Diharapkan
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