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Kerangka Acuan Survey
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PEMERINTAH KABUPATEN CIANJUR DINAS KESEHATAN
PUSKESMAS PUSKESMAS CIPEUYEUM Jl. Raya Bandung Desa Kertamukti Kec. Haurwangi Kab. Cianjur Kode Pos : 43283 Telp : 0263 – 322076 SMS/WA : 083112822317 Email :
[email protected]
KUESIONER JENIS PELAYANAN DI PUSKESMAS CIPEUYEUM
I.
II.
IDENTITAS RESPONDEN
1. No Responden
: ....................... ........... ........................ ........................ ....................... ............. ..
2. Jenis Kelamin
: ....................... ........... ........................ ........................ ....................... ............. ..
3. Umur
: ......................... .................................... ....................... ........................ ............
4. Alamat
: ....................... ........... ........................ ...................... ....................... ............... ..
PERTANYAAN
1. Apakah anda mengetahui tentang jenis-jenis jenis-j enis pelayanan yang ada di Pus Cipeuyeum? Ya. tidak 2. Apakah anda membutuhkan jenis pelayanan yg kami sediakan (pilihan bisa lebih dari satu) Kebutuhan No
Jenis Pelayanan Ya
Tidak
1. Pelayanan pelayanan umum
2.
Pelayanan KIA ( Kesehatan Ibu dan Anak ) dan KB ( Keluarga Keluarga Berencana Berencana )
3. Pelayanan Imunisasi SDIDTK 4. Pelayanan Kembang Anak )
(
Tumbuh
5. Pelayanan Kesehatan Gigi dan mulut 6. Pelayanan Unit Gawat Darurat (UGD ) 7. Pelayanan Persalinan 24 jam
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8. Pelayanan Laboratorium Sederhana
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3. Menurut anda jenis pelayanan apa saja yang anda butuhkan di Puskesmas Cip selain jenis pelayanan yang sudah ada?
................................................................................................................................. ..............................................................................................................................
................................................................................................................................. 4. Apakah anda tahu hak dan kewajiban pasien?
.................................................................................................................................
5. Apakah jadwal pelayanan sesuai dengan yang ada?
.................................................................................................................................
6. Saran dan kritik anda tentang Program Kesehatan Masyarakat di Pus Cipeuyeum ..............................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
.................................................................................................................................
7. Apakah anda puas dengan pelayanan kami? a. Puas b. Kurang puas c. Tidak puas
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