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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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JUMLAH UPAYA KESEHATAN BERSUMBER MASYARAKAT (UKBM)
DI PUSKESMAS.......................
Sheet Music
BULAN..........................TAHUN..........................
NO
DESA/KELURAHAN
POSKESTREN
POSBINDU PTM
POS LANSIA
POS TB DESA
POSMALDES
POKMAIR
POS UKK
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
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UKBM LA (SEBUT
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Kolom # : ¨ah pokmair "ang ada di desa#kelurahan
Sheet Music
Kolom $ : ¨ah pos (KK "ang ada di desa#kelurahan )! sampai dengan kolom *! Kolom 10 : ¨ah (K'M "ang tidak termasuk di dalam (K'M di kolom )!
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Kolom # : ¨ah pokmair "ang ada di desa#kelurahan
Sheet Music
Kolom $ : ¨ah pos (KK "ang ada di desa#kelurahan )! sampai dengan kolom *! Kolom 10 : ¨ah (K'M "ang tidak termasuk di dalam (K'M di kolom )!
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8.2.1.1- SOPPenilaian,
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DATA %ILAYAH ADMINISTRASI PUSKESMAS......................... BULAN &&&&&.. TAHUN &&&&&..
NO
DESA/KELURAHAN
LUAS %ILAYAH
(1)
(2)
(3)
$
+isobahili
2
Namohalu
JUMLAH DUSUN
KATE'ORI %IL
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Kolom :¨ah penduduk se7ara, perkiraan dan#atau perlindungan, serta perubahan dari %aktu ke %aktu berdasarkan data sur9ei kependudukan dari badan "ang ber%enang melakukan sur9ei 'P+, 'adan +ur9ei daerah, dll!.
Kolom : 'erisi ¨ah rumah tangga "ang ada di Pro9insi menurut Kabupaten#Kota berdasarkan data sur9ei kependudukan terakhir dari badan "a ber%enang melakukan sur9ei 'P+, 'adan +ur9ei daerah, dll!. Data dapat berupa data tahun periode pelaporan.
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8.2.1.1- SOPPenilaian,
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DATA KEPENDUDUKAN PUSKESMAS..................................
BULAN &&&&&&&.. TAHUN &&&&&&&&&&
Sheet Music
LAKILAKI NO
DESA/KELURAHAN
(1)
(2)
JUMLAH PENDUDUK
(3)
JUMLAH RUMAH TAN''A
(4)
KEPADATAN PENDUDUK /M2
(5)
PEREMPUAN
KELOMPOK UMUR (TAHUN) 0 14
1 !4
!
(6)
(7)
(8)
JUMLAH
(9)
LAKILAKI PEREMPUAN
KELOMPOK UMUR (TAHUN) 0 14
1 !4
(10)
(11)
KELOMPOK UMUR (TAHUN)
JUMLAH
!
0 14
(12)
(13)
1 !4
(14)
(15)
+isobahili
0
0
0
0
0
Namohalu
0
0
0
0
0
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0
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-rahili
0
/si%a
0
'erua
0
ilibanua
0
0
+isarahili
0
0
4asara Tuhenakhe I
Useful 0
0
JUMLAH
!
0
(16)
(17)
0
00 0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
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8.2.1.1- SOPPenilaian,
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DATA DESA SIA'A PUSKESMAS .................. ........ BULAN &&&&&& TAHUN &&&&&&&&&&.
Sheet Music PENTAHAPAN DESA DAN KELURAHAN SIA'A AKTI N0
(1)
DESA/KELURAHAN
(2)
JUMLAH
JUMLAH DUSUN
(3)
PRATAMA
MADYA
PURNAMA
MANDIRI
(4)
(5)
(6)
(7)
JUMLAH POSKESDES YAN' BEROPERASI
(8)
JUMLAH YAN' DILATIH
KADER
TOMA
TO'A
KADER
TOMA
(9)
(10)
(11)
(12)
(13)
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA SEKOLAH YAN' MEMPROMOSIKAN KESEHATAN DI PUSKESMAS ......................... BULAN &&&&&&&. TAHUN.................. $.
+ekolah Dasar "ang Mempromosikan Kesehatan
JUMLAH SEKOLAH DASAR NO (1)
JUMLAH SEKOLAH YAN' MEMILIKI UKS
DESA/KELURAHAN (2)
JUMLAH SEKOLAH YAN' MEMPROMOSIKAN KESEHATAN
NE'ERI
S%ASTA
JUMLAH
NE'ERI
S%ASTA
JUMLAH
SM
(3)
(4)
(5)
(6)
(7)
PERSENTASE SEKOLAH YAN' MEMPROMOSIKAN KESEHATAN
(8)
(9)
0
0
0
(13)
DI;#0<
0
0
0
DI;#0<
0
0
0
0
0
0
0
0
0
0
0
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
DI;#0< 0 up to vote on this titleDI;#0< Sign 0
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DI;#0< DI;#0< DI;#0<
KETERAN'A
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
Search document
+ekolah Menengah Pertama "ang Mempromosikan Kesehatan
JUMLAH SEKOLAH MENEN'AH PERTAMA
NO
DESA/KELURAHAN
(1)
(2)
NE'ERI
S%ASTA
JUMLAH
(3)
(4)
(5)
JUMLAH SEKOLAH MENEN'AH PERTAMA JUMLAH SEKOLAH MENEN'AH PERSENTASE SEKOLAH YAN' YAN' MEMILIKI UKS PERTAMA YAN' MEMPROMOSIKAN MEMPROMOSIKAN KESEHATAN KESEHATAN BERDASARKAN STRATA NE'ERI S%ASTA JUMLAH SM (6)
(7)
(13)
(8)
(9)
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
0
0
0
0
0
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
DI;#0< Sign 0 up to vote on this titleDI;#0< 0
0
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
Search document
+ekolah Menengah >tas "ang Mempromosikan Kesehatan
JUMLAH SEKOLAH MENEN'AH ATAS
NO
DESA/KELURAHAN
(1)
(2)
JUMLAH SEKOLAH MENEN'AH ATAS YAN' MEMILIKI UKS
NE'ERI
S%ASTA
JUMLAH
NE'ERI
S%ASTA
JUMLAH
JUMLAH SEKOLAH MENEN'AH ATAS YAN' MEMPROMOSIKAN KESEHATAN BERDASARKAN STRATA SM
(3)
(4)
(5)
(6)
(7)
PERSENTASE SEKOLAH YAN' MEMPROMOSIKAN KESEHATAN
(13)
KETERAN'A
(8)
(9)
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
0
0
0
0
0
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
0
0
0
DI;#0<
DI;#0< Sign 0 up to vote on this titleDI;#0< 0
0
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA PHBS RUMAH TAN''A DI PUSKESMAS ......................
BULAN &&&&&. TAHUN &&&&&&&&&.
Sheet Music N0
DESA/KELURAHAN
JUMLAH RUMAH TAN''A
JUMLAH RUMAH TAN''A Y' DIPANTAU
RUMAH TAN''A BER PHBS
(1)
(2)
(3)
(4)
(5)
APAIAN ()
KETERAN'AN
(6)
(7)
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Kolom 1 : nomor urut desa#kelurahan dari $ sampai seterusn"a! Kolom 2 : berisi nama desa#kelurahan Kolom 3 : ¨ah rumah tangga di desa#kelurahan sesuai dengan data ¨ah desa#kelurahan di data %ila"ah kolom 1! Kolom 4 : ¨ah rumah tangga "ang dipantau oleh kader#petugas kesehatan boleh dalam populasi atau sampel! Kolom :¨ah rumah tangga ber8P'+ "ang memenuhi $0 indikator Kolom ! : persentase rumah tangga ber8P'+ ¨ah r umah tangga "ang ber8P'+ dibagi ¨ah rumah tangga "ang dipantau dikali $00! Kolom " : berisi keterangan "ang perlu disampaikan terkait data "ang ada misaln"a 7ara pengambilan sampel, dll!
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DATA PUSKESMAS PEMBANTU DAN PSOKESDES DI PUSKESMAS ........................... ... BULAN &&&&&&.. TAHUN &&&&&&
NO
DESA/KELURAHAN
JUMLAH PUSKESMAS PEMBANTU
(1)
(2)
(3)
JUMLAH POSKESDES (4)
JUMLAH PELAYANAN KESEHATAN TRADISIONAL
(5)
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA TENA'A PROMOSI KESEHATAN DI PUSKESMAS .....................
Sheet Music
BULAN &&&&&..TAHUN............
NO
NAMA PETU'AS
STRUKTURAL
NON UN'SIONAL PKM
(1)
(2)
(3)
(4)
UN'SIONAL PKM AHLI
TERAM
(5)
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Kolom ! : Bungsional Pen"uluh Kesehatan Mas"arakat Terampil adalah petugas promosi kesehatan "ang melakukan tugasn"a diPuskesmas dan telah mengikuti diklat &abatan 6ungsional terampil, mendapat serti6ikat, dan mempun"ai +K .
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DATA PERAN SERTA OR'ANISASI KEMASYARAKATAN DI PUSKESMAS ...................... BULAN &&&&&&&. TAHUN &&&&&&.
1.
OR'ANISASI KEA'AMAAN
NO
DESA
(1)
(2)
JUMLAH ORMAS C>N5 '/?P-T/N+I
C>N5 '/?P/?>N +/?T>
(3)
(4)
NAMA OR'ANISASI
BENTUK KEMITRAAN
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OR'ANISASI PEMUDA
NO
DESA
(1)
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JUMLAH ORMAS C>N5 '/?P-T/N+I
C>N5 '/?P/?>N +/?T>
(3)
(4)
NAMA OR'ANISASI
BENTUK KEMITRAAN
(5)
(6)
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OR'ANISASI %ANITA
NO
DESA
(1)
(2)
JUMLAH ORMAS C>N5 '/?P-T/N+I
C>N5 '/?P/?>N +/?T>
(3)
(4)
NAMA OR'ANISASI
BENTUK KEMITRAAN
(5)
(6)
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Lm S567 M879:; (LSM)/ No< 'o=9m<; O9<>?;>o< (N'O)
NO
DESA
(1)
(2)
JUMLAH ORMAS C>N5 '/?P-T/N+I
C>N5 '/?P/?>N +/?T>
(3)
(4)
NAMA OR'ANISASI
BENTUK KEMITRAAN
(5)
(6)
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OR'ANISASI PROESI
NO
DESA
(1)
(2)
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JUMLAH MITRA C>N5 '/?P-T/N+I
C>N5 '/?P/?>N +/?T>
(3)
(4)
NAMA OR'ANISASI
BENTUK KEMITRAAN
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(6)
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA MITRA DI PUSKESMAS ................ BULAN &&&&&&. TAHUN &&&&&& 1.
DUNIA USAHA/S%ASTA
NO
DESA
(1)
(2)
JUMLAH MITRA C>N5 '/?P-T/N+I
C>N5 '/?MIT?>
(3)
(4)
NAMA DUNIA USAHA/S%ASTA
BENTUK KEMITRAAN
(5)
(6)
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RUAN' LIN'KUP KERJASAMA
(7)
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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LINTAS SEKTOR
NO
DESA
(1)
(2)
JUMLAH MITRA C>N5 '/?P-T/N+I
C>N5 '/?MIT?>
(3)
(4)
NAMA INSTITUSI
BENTUK KEMITRAAN
RUAN' LIN'KUP KERJASAMA
(5)
(6)
(7)
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA SARANA PROMOSI KESEHATAN DI PUSKESMAS .........................
BULAN &&&&&. TAHUN &&&&&&
Sheet Music NO
NAMA SARANA PROMOSI KESEHATAN
JUMLAH
(2)
(3)
(1) $
-P
2
slide pro&e7tor
)
T;
9ideo
kamera 9ideo
generator set
1
kamera 6oto
3
public address system
* wireless
KEADAAN BARAN' BAIK (4)
RUSAK ()
SUMBER PEN'ADAAN BARAN' (!)
KET (")
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA MEDIA MASSA YAN' DIMANAATKAN DALAM PENYEBARLUASAN INORMASI DI KABUPATEN/KOTA ................... TAHUN &&&&&&&.. T9> %@l< &&&&&&&
1.
MEDIA MASSA ETAK
NO
DESA
(1)
(2)
JUMLAH MEDIA MASSA C>N5 >D>
C>N5 '/?MIT?>
(3)
(4)
BENTUK INORMASI (5)
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MEDIA RADIO
NO
DESA
(1)
(2)
JUMLAH RADIO C>N5 >D>
C>N5 '/?MIT?>
(3)
(4)
BENTUK INORMASI (6)
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8.2.1.1- SOPPenilaian,
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MEDIA TELE+ISI
NO
DESA
(1)
(2)
JUMLAH TELE+ISI C>N5 >D>
C>N5 '/?MIT?>
(3)
(4)
BENTUK INORMASI (6)
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8.2.1.1- SOPPenilaian,
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MEDIA TRADISIONAL
NO
DESA
(1)
(2)
JUMLAH MEDIA C>N5 >D>
C>N5 '/?MIT?>
(3)
(4)
BENTUK INORMASI (6)
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8.2.1.1- SOPPenilaian,
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DATA PENIN'KATAN KAPASITAS PETU'AS PROMOSI KESEHATAN
Sheet Music
DI PUSKESMAS ................ BULAN............TAHUN &&&&&&
NO
NAMA PETU'AS PROMOSI KESEHATAN
PELATIHAN YAN' DIIKUTI
TAHUN PELATIHAN
(1)
(2)
(3)
(4)
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MEDIA PROMOSI KESEHATAN PUSKESMAS ........................
Sheet Music
BULAN &&&&& TAHUN &&&&&&..
NO
NAMA DESA
(1)
(2)
MEDIA ETAK JENIS MEDIA (3)
TENTAN' (4)
MEDIA ELEKTRONIK JENIS MEDIA (5)
TENTAN' (6)
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MEDIA JENIS MEDIA (6)
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LAPORAN DESA YAN' MEMANAATKAN DANA DESA UNTUK UKBM BULAN &&&&.. TAHUN &&&& PUSKESMAS -&&&&&&&&&&&&
No $ 2 )
Nm D8
J@ml Alo:8> D< D8
Alo:8> D< Sign up to vote on this title D8 @<;@: UKBM
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8.2.1.1- SOPPenilaian,
KERANGKA ACUAN
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DATA POSYANDU PUSKESMAS ...................... BULAN &&&&&&. TAHUN &&&&&&&&.
NO $ 2 )
NAMA DESA
JLH POSYANDU
STRATA PRATAMA JLH
MADYA JLH
PURNAMA
JLH
MANDIRI JLH
JLH KADER
JLH KADER TERLATIH
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