Tujuan tim FMEA:

____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________

Tanggung jawab tim:

 Melakukan analisis
 Menyusun rekomendasi perbaikan
 Melaksanakan perbaikan
Proses yang diteliti melibatkan unit-unit atau petugas kesehatan dari disiplin keilmuan, yaitu:

1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
6. ___________________________________________________________________________
7. ___________________________________________________________________________

Anggota tim FMEA mewakili unit-unit/disiplin keilmuan:

1. ___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
6. ___________________________________________________________________________
7.