KUESIONER KUESIONE R OTOPSI VERBAL KEMATIAN KEMATIAN PERINATAL, PERINATAL, NEONAT NEONATAL, BAY BAYII & BALITA A. IDENTI IDENTIT TAS ORANG ORANG TUA 1. Nama ibu / ayah !. A"ama# "$%'a( ). Umu* +*a% #ua . P$'$*-aa% +*a% #ua . S#a#u '$"ua*a
ibu ibu
ayah ayah
B. RI0A RI0AYAT KEAMILAN DAN PERSALINAN 1. S#a#u '$hami"a% !. Umu* '$hami"a% '$hami"a% ibu ibu aa# m$"ahi*'a% m$"ahi*'a% bayi bayi / ba"i#a ba"i#a i%i ). Immu%iai ibu TT 1 ya / #i2a' TT ! ya / #i2a' Ti2a' TT ya / #i2a' . B$*a(a 'a"i ($*i'a '$hami"a% . Dima%a ($*i'a '$hami"a% 3. Ri4aya# ($*a"i%a% Pa*#u "ama ya / #i2a' K$#uba% K$#uba% P$5ah P$5ah Di%i Di%i ya / #i2a' #i2a' P$ P$*2a*aha%/ AP ya ya / #i2a' 2a' P$%+"+% P$%+"+% P$*a"i%a% P$*a"i%a% '$"/DTT/DT '$"/DTT/DT/Bi2a /Bi2a%/D+'# %/D+'#$* $* D+'#$* ah"i/%a'$ ah"i/%a'$ "ai% Ai* '$#uba% 6. IDENTITAS IDENTITAS NEONAT NEONATAL, BAYI BAYI DAN BALITA 1. Nama !. Umu* / Ta%a" "ahi* ). 7$%i '$"ami% La'i8"a'i / ($*$m(ua%. . N+ u*u u*u## '$"a '$"ahi hi*a *a% % a%a' a%a' i%i i%i . B$*a# "ahi* 3. Ta%a" m$%i%a" 9. Umu* 4a'#u m$%i%a"
D. RI0A RI0AYAT PENYAKIT PENYAKIT 1. K$a2aa K$a2aa% % (a2a 4a'# 4a'#u u "ahi* "ahi* Ku*u / L$bih L$bih '$5i" '$5i" / N+*m N+*ma" a" $a*# *a#$ /m$%i#. Kua# / L$mah, Ri#mi / A*i#mi R$(i*ai / m$%i#. Ri#mi / A*i#mi. !. S$b$"um m$ m$%i%a", ($ ($*%ah 2i 2i#+"+% a. Ti2a'. ya / #i2a' b. Du'u% bayi. ya / #i2a' 5. Bi Bi2a% 4a#a. ya / #i2a' 2. P$*a4a# 4a#a. ya / #i2a'
$. D+'#$* 4a#a :. D+'#$* ($ia"i. ). T$m(a# m$"ahi*'a% a. Rumah. b. Pu'$ma ($mba%#u. 5. Pu'$ma / *a4a# i%a( 2. Bi2a% P*a'#i' 4a#a $. Rumah a'i# M$2i'a Mu"ya :. Lai%8
ya / #i2a' ya / #i2a' ya / #i2a' ya / #i2a' ya / #i2a' ya / #i2a' ya / #i2a'
"ai% ................................................................................................................... . A(a'ah a2a #a%2a8#a%2a bb a. Pa%a A2a / #i2a' b. S$a' %a:a A2a / #i2a' 5. T$*$2a' / a(i*ai A2a / #i2a' 2. K$bi*ua% A2a / Ti2a' $. K$-a%8'$-a% A2a / Ti2a' :. Mu"u# m$5u5u $($*#i i'a% A2a / Ti2a' . Tiba8#iba #i2a' 2a(a# m$%hia( A2a / Ti2a' h. Lu'a / m$ma* / b$%'a' A2a / Ti2a' i. A%u A2a / Ti2a' -. 6a5a# ba4aa% A2a / Ti2a' Bi"a a2a
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'. Dia*$ ". S#a#u KEP
E. TANGGAL PENERIMAAN LAPORAN KEMATIAN a. Ta%a" m$%$*ima "a(+*a% '$ma#ia% b. Ta%a" ($"a'a%aa% +#+(i ;$*ba" 5. T$m(a# m$%i%a" <. KESIMPULAN S$bab '$ma#ia% ......................................................................................... ......................................................................................... S$*+%a, M$%$#ahui Bi2a%
KUESIONER OTOPSI VERBAL BAYI LAIR MATI A. IDENTITAS IBU 1. Nama ibu !. Nama ayah ). P$'$*-aa% Ibu / Ba(a' . P$%2i2i'a% Ibu / Ba(a' . A"ama# "$%'a( 3. S#a#u K$"ua*a
Umu* Umu* / /
B. RI0AYAT KEAMILAN IBU 1. S#a#u '$hami"a% G P A !. B$*a(a 'a"i $"ama maa '$hami"a% m$m$*i'a'a% 2i*i = >bu'u KIA? a. b. 5. 2.
1 @ ) 'a"i 'a"i 'a"i B$"um ($*%ah
). Dima%a m$m$*i'a'a% '$hami"a%%ya a. b. 5. 2. $.
D+'#$* ah"i D+'#$* Bi2a% Du'u% Lai%8"ai% .......................................................................
. A(a'ah (a2a 4a'#u m$m$*i'a'a% '$hami"a%%ya m$%2a(a# ($"aya%a% T = a. b. 5. 2. $. :.
T
. P$m$*i'aa% '$hami"a% a.
K$hami"a% '$mba*
b. 5. 2. $. :.
O2$ma 'a'i B$a* '$hami"a% $uai umu* '$hami"a% D77 #$*2$%a%, $-a' hami" m, 'ua# / "$mah D77 #a' #$*2$%a*, hami" .. mi%u/-am b"m ($*" L$#a' -a%i% P*$'$(, (*$b+, "i%#a%
3. A(a'ah $"ama '$hami"a% ($*%ah m$%a"ami ha"8ha" $baai b$*i'u# a. Sa'i# 'a*$%a ($%ya'ai# b. 5. 2. $.
i%:$'i b$*a# #hy(u, h$(a#i#i,
TB6, DM, 2"" ................................................................... M$%a"ami #*auma -a#uh, 2""........................ .................... Mi%um +ba#/-amu 2i "ua* R/ 2+'#$* / bi2a% P$*2a*aha% mu"ai umu* '$hami"a% ......................... m M$*aa bayimya #i2a' b$*$*a', $-a' 'a(a% =
6. RI0AYAT PERSALINAN SEBELUMNYA a. Lahi* (+%#a% b. Lahi* 2$%a% #i%2a'a% S6, <+*5$(, Va5um E'#*a'i 5. Lahi* ma#i
D. RI0AYAT PERSALINAN SEKARANG a. b. 5. 2. $. :.
Lahi* (+%#a% Lahi* 2$%a% #i%2a'a% S6, <+*5$(, Va5um E'#*a'i Lahi* ma#i Umu* '$hami"a% )C m ! ha*i K$#uba% P$5ah Di%i Pa*#u "ama
E. RI0AYAT BAYI 1. Ta%a" "ahi* !. B$*a# "ahi* ). K$a2aa% bayi 4a'#u "ahi* a. T$*2a(a# #a%2a8#a%2a IUma#i $b$"um ($*a"i%a%, ma$*ai I @ II @ III, D77 & $*a'a% #i2a' a2a. b. T$*2a(a# #a%2a8#a%2a #i""bi*#h >ma#i aa# ($*a"i%a%, "$bam maya#, ma$*ai #i2a' a2a, D77 & $*a'a% a%a' $b$"um%ya a2a. 5. Ku*u , "$bih '$5i" 2a*i %+*ma". 2. Ta%2a8#a%2a #*auma '$"ahi*a% >h$ma#+ma, "u'a, "$5$#, :*a'#u* ?.
. 0a'#u i ibu mu"ai #i2a' m$*aa'a% $*a'a% bayi a. 2a*i 1 m $b$"um ($*a"i%a%
b. 2a*i 1 m $b$"um ($*a"i%a% 5. Maih m$*aa'a% am(ai aa# ($*a"i%a%
. T$m(a# '$"ahi*a% a. b. 5. 2. $. :. .
Rumah $%2i*i Rumah 2u'u% Rumah bi2a% / BPS P+%2+' b$*a"i% Pu'$ma / Ra4a# i%a( Rumah a'i# Lai%8"ai% ......................................................................
3. P$%+"+% ($*a"i%a% a. b. 5. 2. $. :. .
Du'u% Ta' T$*"a#ih Du'u% T$*"a#ih Bi2a% D+'#$* D+'#$* S($ia"i Na'$ "ai% Lai%8"ai% ........................................................................
<. TANGGAL MENERIMA PELAPORAN KEMATIAN a. M$%$*ima "a(+*a% "ahi* ma#i b. P$"a'a%aa% +#+(i ;$*ba" 5. T$m(a# m$%i%a" G. KESIMPULAN ..............................................IU
