Nama (Name)

Instansi (Institution/University)

Jabatan (Department)

Alamat (Address)

Nomor Telepon (Phone Number)

Email

Nomor Handphone (Mobile Phone Number)

Nomor Whatsapp (Whatsapp number)

No	Pertanyaan (Question)	Jawaban (Answer)		Keterangan / Saran (Remarks / Suggetions)
		Ya (ada) (yes)	Tidak (Tidak Ada) (No)
1	Adakah manfaat dari kerja sama yang dilakukan? Are there benefits from the collaboration done?
2	Adakah kegiatan/program yang dilaksanakan sebagai implementasi kerja sama? Are the activities/programs implemented as an implementation of cooperation?
3	Apakah tujuan dari kerja sama tercapai? Were the goals of the collaboration achieved?
4	Apakah terdapat hambatan/ kendala yang dihadapi dalam pelaksanaan kerja sama? Are there issues encountered during the implementation of cooperation?
5	Jika ada kendala, adakah koreksi dari adanya kerja sama tersebut untuk perbaikan? If there are issues, are there any corrections from the cooperation for improvement?
6	Apakah kerja sama perlu dilanjutkan? Should cooperation continue?

1) Perintisan MoU/ PKS
Drafting and Initiation process of MoU/Cooperation Agreement (CA)

	Pertanyaan Question	jawaban Answer
		Tidak Puas Not satisfied	Kurang Puas Less satisfied	Cukup Puas Quite satisfied	Puas Satisfied	Sangat Puas Very satisfied
a.	Proses pembuatan naskah kerja sama (MoU/MoA/PKS) dilakukan dengan cepat dan tepat ? The process of drafting the MoU/MoA/CA is done properly in a timely manner
b.	Sekretariat bagian kerja sama bekerja dengan profesional dan responsif dalam melayani mitra kerja sama ? The secretariat of the cooperation section works professionally and responsively in serving cooperation partners
c.	Sekretariat bagian kerja sama ramah dalam memberikan pelayanan ? The secretariat for cooperation is friendly in providing feedback
d.	Mekanisme layanan kerja sama selama proses inisiasi kerja sama mudah dan tidak menyulitkan ? The cooperation service procedure is easy during the initiation process
e.	Proses komunikasi dan koordinasi dalam pembuatan naskah kerja sama berjalan dengan baik ? The process of communication and coordination in drafting the MoU/MoA/CA is conducted well?

2) Tindak Lanjut/ Implementasi MoU/ PKS
Follow-up of MoU and Cooperation Agreement Implementation

	Pertanyaan (Question)	jawaban (Answer)
		Tidak Puas (Not Satisfied)	Kurang Puas (Less Satisfied)	Cukup Puas (Quiet Satisfied)	Puas (Satisfied)	Sangat Puas (Very Satisfied)
a.	Kualitas tenaga ahli/ instruktur/ narasumber dari lingkungan Universitas Balikpapan yang menindaklanjuti kerja sama memiliki kompetensi yang sesuai ? The quality of the experts / instructors / resource persons from the Universitas Balikpapan who follow up the collaboration have the appropriate competencies
b.	Universitas Balikpapan memberikan pendampingan yang terbaik untuk memenuhi kebutuhan kami (mitra kerja sama) ? Universitas Balikpapan provides the best assistance to meet partners’ needs
c.	Kegiatan implementasi dari kerja sama sesuai dengan harapan kami (mitra kerja sama) ? The implementation activities of the cooperation are in line with partner’s expectations
d.	Kerja sama antara Universitas Balikpapan dengan Instansi Saudara telah diimplementasikan dengan kegiatan yang sesuai dengan MoU yang telah disepakati Bersama ? The cooperation between Universitas Balikpapan and your institution has been implemented with activities in accordance with the mutually agreed MoU
e.	Universitas Balikpapan secara proaktif menghubungi kami (mitra kerja sama) untuk membuat perencanaan implementasi sebagai tindak lanjut MoU/ PKS yang telah ditandatangani ? Universitas Balikpapan proactively contacted us (collaborating partners) to make an implementation plan as a follow-up to the signed MoU/CA ?
f.	Universitas Balikpapan secara proaktif menawarkan kepada kami (mitra kerja sama) untuk melanjutkan kegiatan kerja sama dalam rangka mengisi MoU/ PKS ? Universitas Balikpapan proactively offers us (partners) to continue cooperation activities in order to fill the MoU/CA
g.	Tindak lanjut kerja sama memberikan manfaat dan dampak positif bagi kami ? Follow-up/Implementation of cooperation provides benefits and positive impact for both of the parties

1) Berdasarkan pengalaman kerja sama bersama Universitas Balikpapan, mohon Ibu/ Bapak berkenan menuliskan hal-hal yang dibutuhkan institusi atau organisasi Ibu/ Bapak dalam kaitannya dengan keberlanjutan kerja sama di masa yang akan dating ?
Based on the experience of collaborating with the Universitas Balikpapan, would you please write down the things that your institution or organization needs in relation to the sustainability of the cooperation in the future?

2) Jika kerja sama/ MoU telah berakhir, perlukan perpanjangan ? (sebutkan alasannya)
If the cooperation/MoU has ended, do you fell an extension will be needed? (state the reason)

3) Usulan kegiatan atau program yang dibutuhan institusi atau organisasi dalam kerangka kerja sama standardisasi dan penilaian kesesuaian (SPK) ? (Sebutkan)
Proposed activities or programs needed by institutions or organizations within the framework of standardization and conformity assessment (Cooperation Agreement) cooperation? (mention)

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