Form Identifikasi Kerusakan Bangunan Sekolah mPyU

 

OI\ERCD\ ^BFDCADAF MB\R[AMAF LAFHRFAF

7 Faea [bmicaj

[EM ........... 7 ….

F^[F Faea Lafhufaf

7 Lafhufaf Mbcas 1 -;

FR^ (Fi Rrut ^bricbjaf)

7 7 Gc. Pdeur Larat

 Acaeat Malupatbf/Mita

7 Malupatbf

Miir`dfat

7

Cuas Lafhufaf

7 1>>

^rivdfsd

7

e<

Gawa Larat

Guecaj Caftad

7

1

MCA[DODMA[D MB\R[AMAF FI

MIE^IFBF

[RL MIE^IFBF

(1)

(.

>.0>

>.?>

>.:>

1.>>

(?)

(8)

(:)

(4)

(1>)

PDFHMAP MB\R[AMAF

(11)

>%

Pd`am a`a mbrusamaf

1

^IF@A[D

^if`asd

<

[P\RMPR\

Micie

ufdt

:.>>

>.>>

>.>>

>.>>

>.>>

>.>>

>%

Lacim

ufdt

:.>>

>.>>

>.>>

>.>>

>.>>

>.>>

>%

^bcat

ufdt

0.>>

>.>>

>.>>

>.>>

>.>>

>.>>

>%

 

bstdeasd

;

APA^

%

>.>>

>.>>

>.>>

>.>>

>.>>

>. >>%

0

^CAOIF@

%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

2

@DF@DFH

Latu lata/^artdsd

%

Maka

ufdt

0

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

^dftu

ufdt

<

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

Musbf

ufdt

?

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

?

CAFPAD

^bfutup Caftad

%

8

RPDCDPA[

Dfstacasd Cdstrdm

bseasd

 Pd`am a`a mbrusamaf

>.>>%

Dfstacasd Adr 

bseasd

 td`am a`a mbrusamaf

>.>>%

@radfasb Cdelaj

:

ODFD[JDFH

Odfdsjdfh Cafhdt-cafhdt Odfdsjdfh @df`dfh Odfdsjdfh Musbf/^dftu

e1

1

% % ufdt

?

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>%

>.>>

>.>>

>.>>

>.>>

>.>>

>.>>% >.>%

Jdtufh Mbrusamaf Miepifbf Cadf

>%

Jdtufh Mbrusamaf Miepifbf Cadf

Jdtufh Mbrusamaf Miepifbf Cadf

>% Jdtufh Mbrusamaf Miepifbf Cadf

Pd`am A`a Mbrusamaf

 

[MBP[A @BFAJ LAFHRFAF

Katataf

Pdfhmat Mbrusamaf \d \dfh fhaf af 7 ≠ ;> ;>% % [b`afh [b`af h 7 6 ;>% - 02% 02% Lbrat 7 6 02%

PDE [R\_BD 7 ^btuhas [urvby

(.................................................) EBFTBPRGRD @dfas Mblu`ayaaf ^bf`d`dmaf Mal/Mita/^rivdfsd

(.................................................) EBFHBPAJRD @dfas ^R Mal/Mita/^rivdfsd*

(.................................................) Fitb 7 *

7 @dfas ^R/@dfas yafh ebfafhafd Lafhufaf Hb`ufh

 

MI@B [R\_BD 7

OI\ERCD\ [R\_BD LAFHRFAF PB\MBFA @AE^AM HBE^A LRED ^\I_DF[D FR[A PBFHHA\A LA\AP PAJRF 1: Faea Dfstafsd/^bedcdm Lafhufaf

7

Faea Lafhufaf

7

 Acaeat

7

Miir`dfat

7 ( x) 7

Cuas Lafhufaf Pdpb Lafhufaf

OI\ERCD\ DD

MAL./MIPA 7

............................................................... .................................. ............................................ ............... PAFHHAC [R [R\_BD 7 MBKAEAPAF 7 ..... .......... ..... AHR[PR[ AHR[PR[ 1: .... ......... ......... ......... .......... ......... ......... ......... ....... ...

(`ddsd `bfhaf oireat `bsdeac)

( y)

e< 7 [bed ^breafbf/^breafbf (kirbt yafh td`am sbsuad)

Guecaj Caftad

7

LILIP FI

Miepifbf Lafhufaf

[ul Miepifbf

(1)

(.>>

12

>.>>

>.>>

<

[P\RMPR\

Micie, Lacim, `af ^bcat

>

;>

>.>>

>.>>

F6;>

rusam lbrat

;

APA^ AP

\afhma Atap

:.>>

;>

>.>>

>.>>

^bfutup Atap

>

1>>

>.>>

>.>>

0

^CAOIF@

\afhma Cafhdt-cafhdt ^bfutup Cafhdt-cafhdt

;.2> 0.2>

1>> 1>>

1>.>> 1>.>>

>.;2 >.02

2

@DF@DFH

Latu lata/^artdsd

0.2>

1>>

1>.>>

>.02

1

\usam \dfhaf

^cbstbraf

1.82

1>>

1>.>>

>.1:

>

Pd`am \usam

Maka

1.>

1>.>>

>.1;

>

Pd`am \usam

^dftu

1.>>

1>>

1>.>>

>.1>

>

Pd`am \usam

Musbf

1.2>

1>>

1>.>>

>.12

? 8

CAFPAD RPDCDPA[

^bfutup Caftad Dfstacasd Cdstrdm

1>.>> 2.>>

1>> 1>>

1>.>> 1>.>>

1.>> >.2>

>

Pd`am \usam

Dfstacasd Adr

1.2>

1>>

1>.>>

>.12

@radfasb Cdelaj

1.2>

1>>

1>.>>

>.12

>