FORMAT PENDATAAN PENDATAAN PHBS DI TATANAN TATANAN RUMAH TANGGA RT/RW
: . . .. . . . . .. . .. . . .. . .. . .. . . .. . . . .. . . .. . . .. . . . . .. . .. . . . . .. . . .. . . .. . . . .. . . .
PUSKESMAS
DESA/KELURAHAN
: . . . . .. . .. . . . . .. . . .. . .. . . . . . .. . .. . . . . .. . . .. . .. . . . . .. . . .. . . . . .. . . .. . .. .. .
BULAN PENDATAAN
Identitas
10 Indikator Persalinan
a g r a u l e K a l a p e K o N
h a m u R o N
$
Nama Kepala Keluarga
%
&
n i l a s r e B u b I a d A '
Pemberian ASI Eksklusif
s e k a n i L (
n l b < i y a B
YA YA TIDAK JUMLAH
: .............................................. ................................................................ .................. : .............................................. ................................................................ ..................
Rumah Ber-PHB k i "
r u y a s
k i s i f s
m a l a
Rumah Tan!!a BerPHB
a ! a s I S A )
% $ 1 i y a B h a l m n u l 0 b *
Menimbang
s u l u f l l i b s u % l k $ s 1 k i E y I a S B A +
a " i l a B n a d i y a B a d A
g n a b m i " i #
h i s r e B r i A n a k a n u g g n e M
$,
$$
%$ n a g n n u a b / a i s . u n a d n h a i k s a r e n b u r g i g a n n e g M d $&
n a b m a 0 n a k a n u g " g a n h e e M S $'
YA YA TIDAK JUMLAH
: .............................................. ................................................................ .................. : .............................................. ................................................................ ..................
Rumah Ber-PHB k i " n e 0 s a " n a r e h b a m m u e i r M d $(
r u y a s n a d h a i u r a b h n p a a k i a " e M s
k i s i f s a " i f i " k a n i a r a k h u k p a i a l e " e M s
$
$)
m a l a d i d o k o r e m k h a a d m i u / r $*
Rumah Tan!!a BerPHB
t a h e
t a h e k a d i T
t a h e
t a h e k a d i T
$+
%,
%$
%%
YA YA TIDAK JUMLAH
: .............................................. ................................................................ .................. : .............................................. ................................................................ ..................
Rumah Ber-PHB k i " n e 0 s a " n a r e h b a m m u e i r M d $(
r u y a s n a d h a i u r a b h n p a a k i a " e M s
k i s i f s a " i f i " k a n i a r a k h u k p a i a l e " e M s
$
$)
m a l a d i d o k o r e m k h a a d m i u / r $*
Rumah Tan!!a BerPHB
t a h e
t a h e k a d i T
t a h e
t a h e k a d i T
$+
%,
%$
%%
: .............................................. ................................................................ .................. : .............................................. ................................................................ ..................
Rumah Ber-PHB k i " n e 0 s a " n a r e h b a m m u e i r M d $(
r u y a s n a d h a i u r a b h n p a a k i a " e M s
k i s i f s a " i f i " k a n i a r a k h u k p a i a l e " e M s
$
$)
RT/RW
m a l a d i d o k o r e m k h a a d m i u / r $*
Rumah Tan!!a BerPHB
t a h e
t a h e k a d i T
t a h e
t a h e k a d i T
$+
%,
%$
%%
: ...............................................................
RT/RW
: ...............................................................
DESA/KELURAHAN
: ............................................................... Identitas
# o
$
Nama #esa
%
h a m u R h a l m u 0 &
a l a p a e g K r a h l u a l e K m u 0 '
Persalinan n u i l b I a a s r d e A B (
s e k a n i L
n l b < i y a B )
RT/RW
: ...............................................................
DESA/KELURAHAN
: ............................................................... Identitas
# o
Nama #esa
$
%
YA TIDAK JUMLAH "
h a m u R h a l m u 0 &
a l a p a e g K r a h l u a l e K m u 0 '
Persalinan n u i l b I a a s r d e A B (
s e k a n i L
n l b < i y a B )
FORMAT REKAPITULASI PENDATAAN PHBS DI TATANAN RUMAH TANGGA TAHUN 2016 ...... ...... 10 Indikator Pemberian ASI Eksklusif a ! a s I S A *
i y a n B l h b a ) l 1 m u 0 +
Menimbang l b I f % S i s $ u 1 A l s k i l u s y u k a l E B $,
n a d i " a y i a l a B B a d A $$
g n a b m i " i #
%$ r i A n a k h a i n s r u e g B g n e M $&
i . n u i r u - a b n n a a g s k d n a a n n d u a h g g i g n s a n / r e e b M $'
n " a a k h e a S n u n g a g b n m e a M 0 $(
WILAYAH KERJA PUSKESMAS
: ............................... ...............................
BULAN PENDATAAN
: ............................... ...............................
k i " n e 0 s h a a " n m u a r r i e d b m e M $
n i r a a d h h p a i a u " b e n s a r k u a y a M s $)
s a i " r i f i a " h k a p a n i a " k e u s k k a i s l f e i M $*
Rumah Ber-PHB o h k a o r m e u r m m k l a a a d i d / i d $+
Rumah Tan!!a BerPHB
t a h e
t a h e k a d i T
t a h e
t a h e k a d i T
%,
%$
%%
%&
FORMAT PENDATAAN P HBS DI TATANAN PENDIDIKAN TAHUN 2016
KELAS
: .......................................................................
KECAMATAN
JUMLAH SISWA
: .......................................................................
WILAYAH KERJA PUSKESMAS
NAMA SEKOL AH
: . .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. ... .. .. .. .. .. .. ... .. .. .. .. ... .. .. .. .. .
B ULA N P ENDATAAN
: 14 I N D I K A T O R
NO
NAMA SISWA
1
2
2A /I#AK 03MLA4
: ......................................................... : ......................................................... : .........................................................
t u b m " a a R ! a r h i a r h i e l B e h i m r # e a g a M A R 3
" i h a # i a a $ R a % " i a a $ & h a i m e r e M B 4
$ u e $ ! u " e ' % a u h r l a a i h l r i l e e e B r m a " e g a M A & 5
u h t i a # # a e R S " i a a $ & a h i m e e M B 6
r u t a r e ) a r g u a $ R u h r e a ) l ( r " e a B & 7
i & $ ( $ ( r e h a l M ( $ $ ! i e ) S 8
" a $ a " u g g " e M A $ * a % ! i A ) N 9
$ h i t a " l ( e $ + e a S t i " & a r $ e b u m m e a , M N 10
h i r e B " a g $ " t a a a " - h u " e g a S g b " " e m a a & M + 11
2A /I#AK 03MLA4
: ......................................................... : ......................................................... : .........................................................
r i A " a $ a " u g h g i " e r e M B 12
r i l a g " " a e g M " r a i " ) u i A b . " a u a S . g " " " e e a M & & 13
1 a h h i , a a r a # # 0 0 h a h i ! h m m a g a t l " b a a h i a m a ( S S a a r r u h $ l B e e i g t e e # h ' B " a " S h a # r ( " a h e a a u m $ ) # # # " i b e g g a " t " ) " m m " a " a m 2 e e e a S a a a a ' M ' - / S S M + 14 15
" a t i l a r g u e g B B i " # a g " ) i " a r t a u e $ S b & m " u i g " a a " ! " ! e a e a M B M B 16
: ......................................................... : ......................................................... : .........................................................
r i A " a $ a " u g h g i " e r e M B 12
r i l a g " " a e g M " r a i " ) u i A b . " a u a S . g " " " e e a M & & 13
1 a h h i , a a r a # # 0 0 h a h i ! h m m a g a t l " b a a h i a m a ( S S a a r r u h $ l B e e i g t e e # h ' B " a " S h a # r ( " a h e a a u m $ ) # # # " i b e g g a " t " ) " m m " a " a m 2 e e e a S a a a a ' M ' - / S S M + 14 15
" a t i l a r g u e g B B i " # a g " ) i " a r t a u e $ S b & m " u i g " a a " ! " ! e a e a M B M B 16
JUMLAH SASARAN/SEKOLAH KECAMATAN
: ................................... :
JUMLAH SASARAN/SEKOLAH KECAMATAN
: ................................... : ................................... :
NO
NAMA S'OA -AN &I%AN)A
+MA SISWA
1
2
3
Memelihara Mema$ai Rambut Agar %a$aia" Berih Berih !a" &a" Ra#ih Ra#ih
4
5
JUMLAH SASARAN/SEKOLAH KECAMATAN
: ................................... : ................................... :
NO
NAMA S'OA -AN &I%AN)A
+MA SISWA
1
2
3
2A /I#AK 03MLA4 5
Memelihara Mema$ai Rambut Agar %a$aia" Berih Berih !a" &a" Ra#ih Ra#ih
4
5
FORMAT REKAPITULA .............................................. .............................................. 14 I N D I
Memelihara 'u$u Agar elalu %e"!e$ &a" Berih
Mema$ai Se#atu Beih &a" Ra#ih
6
7
Ber(lah Raga )i!a$ )i!$ Mer($($ )eratur &a" Me"ggu"a$a" &i Se$(lah )eru$ur NA%*A
8
9
10
I PENDATAAN PHBS DI TATANAN PENDIDIKAN TAHUN 2016 WILAYAH KERJA PUSKES BULAN PENDATAAN KATOR
Me".u.i Me"ggu"a$a" Membera"ta )a"ga" +amba" -a"g Me"ggu"a$a" +e"ti$ N,amu$ &e"ga" Air Berih &a" Air Berih &i Se$(lah Me"galir &a" Sehat Sabu"
11
12
13
14
Me"bua"g Sam#ah 'e )em#at Sam#ah -a"g )er#ilah /Sam#ah Baah Sam#ah 'eri"g Sam#ah Berbaha,a 15
AS
: ................................................................................. : ................................................................................. STATUS
Me"imba"g Me"g$("umi Berat Ba!a" +aa"a" ehat &a" Me"gu$ur !ari 'a"ti" )i"ggi Ba!a" Se$(lah Setia# Bula"
16
17
DIPANTAU
B!" PHBS
T#$%& B!" PHBS
SASARAN
YANG DIPANTAU
18
19
20
21
-AN Ber %BS
22
FORMAT PENDATAAN PHBS DI INSTITUSI KESEHATAN TAHUN 2016 DESA/KELURAHAN
: ...................................................
WILAYAH KERJA PUSKESMAS
KECAMATAN
: ...................................................
BULAN PENDATAAN ' I N DI K AT O R
NO
NAMA FASILITAS KESEHATAN
1
2
M(-*-# %()%( M*%() M())*(%&%( $()%( %#! M())*(%&%( S%3%, P%$% A#! B!+#, !+#, %() J%%( T3%(% ()%#! $%( +%*( 3
4
5
6
T#$%& M!&& D# I(+#*+# K+,%%(
T#$%& M*$%, S%!%()%(
7
8
::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::
STATUS FASILITAS KESEHATAN
M!%(%+ J(#& N%*&
B!"PHBS
T#$%& B!"PHBS
9
10
11
FORMAT REKAPITULASI PE
JUMLAH SASARAN
: .....................
::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::
STATUS FASILITAS KESEHATAN
M!%(%+ J(#& N%*&
B!"PHBS
T#$%& B!"PHBS
9
10
11
FORMAT REKAPITULASI PE
JUMLAH SASARAN KECAMATAN
: ............................................... : ............................................... ' I
NO
NAMA FASILITAS KESEHATAN
1
2
( % & % , ( # * + ) ! ) B ( ! # M A 3
( % ) ( ( ) % ! ( % $ # . % % ! # 0 2 - ( # % * % , # ) ( - ) * ( ( ( + / ! % M $ / 1 + 4
( % & % ( * ( ) % ) / ( 1 % M J 5
FORMAT REKAPITULASI PE
JUMLAH SASARAN KECAMATAN
: ............................................... : ............................................... ' I
NO
NAMA FASILITAS KESEHATAN
1
2
YA TIDAK JUMLAH 5
( % & % , ( # * + ) ! ) B ( ! # M A 3
( % ) ( ( ) % ! ( % $ # . % % ! # 0 2 - ( # % * % , # ) ( - ) * ( ( ( + / ! % M $ / 1 + 4
( % & % ( * ( ) % ) / ( 1 % M J 5
DATAAN PHBS DI INSTITUSI FASILITAS KESEHATAN TAHUN 2016 .... ....
WILAYAH KERJA PUSKESMAS BULAN PENDATAAN
DIKATOR % $ ) % % P 0 ( % ( , . * % / % 3 3 1 1 % 1 M S T 6
: ................. : ................. STATUS
& 4 & # 4 ! + ( % * . . # M . % & + , ( % I + $ # # T D K 7
, ( % $ % * ) 2 ( % ! M % / & % 1 $ # T S 8
+ & % * . ( 1 % % ! 0 N / & # . 1 ( M J 9
B!"PHBS
T#$%& B!" PHBS
10
11
.................................... .................................... DIPANTAU
SASARAN
YANG DIPANTAU
12
13
FORMAT PENDATAAN PHBS DI TATA TAHUN 20 DESA/KELURAHAN KECAMATAN
: ................................................... : ................................................... 6 IN&
NO
NAMA ))
1
2
" a $ h a i r " u e g b g i r " a e M 3
" a $ a " " a u b g m g a " 2 e M 4
a g ! a " a , a # t " u h a b a # m # m e m e M a t 5
NAN TEMPAT"TEMPAT UMUM 16 WILAYAH KERJA PUSKESMAS BULAN PENDATAAN
::::::::::::::::::::::::::::::::::::::::::::::::::::: :::::::::::::::::::::::::::::::::::::::::::::::::::::
I'A)OR
i ! $ m ( u $ m ( r u e t m a # $ m a e ! i t ) 6
STATUS h " a ! a u g " l e a r m a $ b a m ! i e ) 7
$ a u t " m a a r , e " b $ i m t e " e M 2 8
B!" PHBS
T#$%& B!" PHBS
9
10
FORMAT REKAPITULASI JUMLAH SASARAN KECAMATAN
: ................................................... : ................................................... 6 IN&
NO
NAMA ))
1
2
Y% T#$%& J*%, 5
" a $ h a i r " u e g b g i r " a e M 3
" a $ a " " a u b g m g a " 2 e M 4
a g ! a " a , a # t " u h a b a # m # m e m e M a t 5
ENDATAAN PHBS DI TATANAN TEMPAT"TEMPAT UMUM TAHUN 2016 WILAYAH KERJA PUSKESMAS BULAN PENDATAAN
I'A)OR
i ! $ m ( u $ m ( r u e t m a # $ m a e ! i t ) 6
STATUS h " a ! a u g " l e a r m a $ b a m ! i e ) 7
$ a u t " m a a r , e " b $ i m t e " e M 2 8
B!" PHBS
T#$%& B!" PHBS
9
10
: ..................................................... : ..................................................... DIPANTAU
SASARAN
YANG DIPANTAU
YANG B!" PHBS
11
12
13
FORMAT PENDATAAN PHBS DI TATANAN LINGKUNGAN KERJA/KANTOR TAHUN 2016 DESA/KELURAHAN KECAMATAN
: ................................................... : ...................................................
WILAYAH KERJA P BULAN PENDATA INDIKATOR
M()&(+*+# M#,%!% M(-*-# T%()%( M%&%(%( D%!# M*%() M!%(%+ NAMA TEMPAT KERJA/ K!+#,%( $%( M())*(% M())*(%& D()%( A#! B!+#, K%(#( D# S%3%, J(#& N%*& D# KANTOR K!%3#,%( &%( A#! %( J%%( Y%() M()%#! L#()&*()%( P%$% L#()&*()%( L#()&*()%( B!+#, S,% D%( M&%# T3% K7% $%( T%3%(% T3% K!7% T3% K!7% S%*( A%* M%8% B&% D%!# R*%,
NO
1
5
USKESMAS N
6
7
8
9
10
11
: .................................................. : .................................................. STATUS
M%&*&%( O%, R%)%/A	%+ F#+#& S-%!% T!%*!
T#$%& M!&& D##()&*()%( T3% K!7%
B!"PHBS
T#$%& B!" PHBS
13
14
15
16
FORMAT REKA
JUMLAH SASARAN
: ........................
12
USKESMAS N
: .................................................. : .................................................. STATUS
M%&*&%( O%, R%)%/A	%+ F#+#& S-%!% T!%*!
T#$%& M!&& D##()&*()%( T3% K!7%
B!"PHBS
T#$%& B!" PHBS
13
14
15
16
FORMAT REKA
JUMLAH SASARAN KECAMATAN
: ................................................... : ...................................................
M#,%!%
NO
1
NAMA TEMPAT K!+#,%( $%( M())*(%& M())*(%& KERJA/ KANTOR K!%3#,%( %( A#! %( J%%(
2
L#()&*()%( T3% K!7%
B!+#,
S,%
3
4
5
FORMAT REKA
JUMLAH SASARAN KECAMATAN
: ................................................... : ...................................................
M#,%!%
NO
1
Y% T#$%& J*%, 5
NAMA TEMPAT K!+#,%( $%( M())*(%& M())*(%& KERJA/ KANTOR K!%3#,%( %( A#! %( J%%(
2
L#()&*()%( T3% K!7%
B!+#,
S,%
3
4
5
ITULASI PENDATAAN PHBS DI TATANAN LINGKUNGAN KERJA/KAN TAHUN 2016 WILAYAH KER BULAN PEND INDIKATOR M()&(+*+# M(-*-# T%()%( M%&%(%( D%!# M!%(%+ M*%() D()%( A#! B!+#, K%(#( D# J(#& N%*& S%3%, P%$% Y%() M()%#! L#()&*()%( T3% D# L#()&*()%( T%3%(% D%( M&%# K7% $%( A%* T3% K!7% S%*( M%8% B&% D%!# R*%, 6
7
8
9
