FORMULIR PENILAIAN PSIKOLOGI LOMBA BALITA SEHAT.pdf

PENILAIAN PSIKOLOGI LOMBA BALITA SEJAHTERA INDONESIA (LBSI) TINGKAT KECAMATAN ................. TAHUN ............

LEMBAR NILAI Nomor Peserta : ..................................... ..................................... Nama Peserta

: .............................. ..................................... .......

Usa

: ...... B!"a# ...... Har

Ut!sa#

: Pos$a#%! ........................

Nama A$a&

: .................................... ......................................

Nama I'!

: ................................... ..................................... ..

A"amat

: ................................... ..................................... ..

Desa

: ................................... ..................................... ..

Keamata#

:

Ka'!ate#

:

Pro#s

:

a. N"a %asar ****************** **************************** *************.***** ***.***** :

+,

'. N"a tem %a"am re#ta#- !sa se'e"!m#$a $a#- t%a %!/a# •

Item #o 0 s1% 2,

: ** tem 3 0 4 **

•

Item #o 20 s1% 056

: ** tem 3 + 4 **

. N"a tem $a#- mam! %"a!a# a#a %ar re#ta#- !sa $a#- %!/a# •

Item #o 0 s1% 2,

: ** tem 3 0 4 **

•

Item #o 20 s1% 056

: ** tem 3 + 4 ** N"a $a#- %ero"e&

Kemam!a# a#a :

N"a $a#- %ero"e& Usa a#a ('!"a#)

:

**

4 ******

Sumber : Yayasan Kesejahteraan Anak Indonesia, 1997, Di ketik ulang oleh Manjilala htt!:""gi#imu$%om&

1

PETUNJUK PENILAIAN PSIKOLOGI KELOMPOK UMUR 6-24 BULAN DAN 2-5 TAHUN

Mo&o# Per&ata# DENGAN BAIK et!#/! % 'a7a& # se'e"!m me"a!a# e#-!/a# 8 0. Pe#"aa# %"a!a# 'er%asara# 7a7a#ara %e#-a# ora#- t!a9 e#-as!& ata! e"!ar-a "a##$a 8 6. U#t! me#/a-a s!'$ettas %a# e'e#ara# e#"aa#9 '"a er"! e#"a %aat me"a!a# e#-!/a# "a#-s!#- a%a a#a $a#- %#"a. +. Ber #"a 0 !#t! seta &a" $a#- %aat %"a!a# a#a %a# #"a , !#t! $a#- t%a1'e"!m %aat %"a!a# a#a. ;. M!"a"a& %e#-a# tem<tem $a#- 'era%a %a"am re#ta#- !sa $a#- ses!a %e#-a# !sa a#a (%a#--a 'a&7a a#a te"a& mam! me"a!a# tem<tem $a#- a%a a%a e"omo re#ta#!sa se'e"!m#$a) Misalnya : U#t! a#a !sa 0, '!"a#9 e#"aa# %m!"a %ar tem #o. 05 %a"am re#ta#- !sa 2 '!"a# 05 &ar s1% 06 '!"a# 0= &ar. Aa'"a emam!a# a#a %ra-!a#9 e#"aa# %aat %m!"a %e#-a# tem<tem a%a e"omo re#ta#- !sa se'e"!m#$a. Pa%a o#to& % atas %aat %m!"a %ar tem No. 0 a%a re#ta#- !sa 5 '!"a# s1% 2 '"a# 0= &ar. =. Pe#"aa# %&e#ta# '"a % a#tara te a%a $a#- %er!#t!a# 'a- re#ta#- !sa terte#t!9 t%a a%a sat!!# $a#- 'er&as" ata! mam!%"a!a# a#a. Msa"#$a : A#a !sa 'er!sa 0= '!"a# + &ar9 $a#- e#-!/a##$a %m!"a %ar tem #o. +0 %a"am re#ta#!sa 06 '!"a# 05 &ar9 t%a %aat me"a!a# sat!!# tem sama %e#-a# re#ta#- !sa 0= '!"a# 05 &ar s1% 0> '!"a# 0= &ar9 ma a e#"aa# %&e#ta# a%a re#ta#- !sa # sa/a. 5. Pe#"aa# Ber #"a %asar +, (a) J!m"a&a# #"a tem $a#- mam! %"a!a# a#a ? 'a %ar re#ta#- !sa se'e"!m#$a $a#t%a %!/a# (') ma!!# $a#- %!/a# () @. Kem!%a# a. U#t! tem No 0 s1% 2, tota" #"a %a"a# 0 '. U#t! tem No 20 s1% 056 tota" #"a  %a"a# + . Has" #"a $a#- %ero"e& a#a a%a"a& e#/!m"a&a# %ar (a') : a. N"a %asar *******************************.***** : +, '. N"a tem %a"am re#ta#- !sa se'e"!m#$a $a#- t%a %!/a# Item #o 0 s1% 2, : ** tem 3 0 4 ** Item #o 20 s1% 056 : ** tem 3 + 4 ** . N"a tem $a#- mam! %"a!a# a#a %ar re#ta#- !sa $a#- %!/a# Item #o 0 s1% 2, : ** tem 3 0 4 ** Item #o 20 s1% 056 : ** tem 3 + 4 ** N"a $a#- %ero"e& : ** • •

• •

>. Kemam!a# a#a a%a"a& N"a $a#- %ero"e& %'a- !sa a#a %a"am '!"a# : N"a $a#- %ero"e& Kemam!a# a#a : Usa a#a ('!"a#)


'

CONTOH : 0. Msa"a# a#a $a#- %!/ 'er!sa 0; '!"a# 0, &ar9 a %!/a# m!"a %ar re#ta#- !sa 06 '!"a# 05 &ar  0= '!"a# 0= &ar9 %a# ter#$ata a mam! me"a!a# 06 tem. Beraaa& #"a $a#a ero"e&  Cara Per&t!#-a# a. N"a %asar ************************************ : 4 +, '. N"a tem %a"am re#ta#- !sa se'e"!m#$a $a#- t%a %!/a# Item #o 0 s1% 2, : +, tem 3 0 4 +, •

(diperoleh dari jumlah item dari rentang usia 6 bulan - 9 bulan 15 hari dan 9 bulan 16 hari – 12 bulan 15 hari)

Item #o 20 s1% 056 : , tem 3 + 4 , . N"a tem $a#- mam! %"a!a# a#a %ar re#ta#- !sa $a#- %!/a# Item #o 0 s1% 2, : 06 tem 3 0 4 06 •

•

(diperoleh dari rentang usia 12 bulan 16 hari – 15 bulan 15 hari) •

Item #o 20 s1% 056

Kemam!a# a#a :

6 0;

=

: , tem 3 + N"a $a#- %ero"e& :

4 , 4 2

= 0; ,

6. A#a 'er!sa + '!"a#9 e#-!/a# %m!"a %ar tem a%a re#ta#- !sa +5 '!"a# 05 &ar  ;> '!"a# 0= &ar9 %a# ter#$ata a mam! me"a!a# ; tem %ar re#ta#- !sa terse'!t. Beraaa& #"a $a#- a ero"e&  Cara Per&t!#-a# a. N"a %asar ************************************ : 4 +, '. N"a tem %a"am re#ta#- !sa se'e"!m#$a $a#- t%a %!/a# Item #o 0 s1% 2, : 2, tem 3 0 4 2, Item #o 20 s1% 056 : 0> tem 3 + 4 =; • •

(diperoleh dari jumlah item dari rentang usia 24 bulan 16 hari - 36 bulan 15 hari)

. N"a tem $a#- mam! %"a!a# a#a %ar re#ta#- !sa $a#- %!/a# Item #o 0 s1% 2, : , tem 3 0 4 , Item #o 20 s1% 056 : ; tem 3 + 4 06 N"a $a#- %ero"e& : 4 !"6 0>5 = ,6 = ,+ Kemam!a# a#a : + • •

=

,

=

,

Ba#%#-a# emam!a# a#a %e#-a# me"&at &as" a&r #"a emam!a# a#a. A#a $a#me#%aat #"a $a#- "e'& 'esar t!"a& $a#- mem" emam!a# $a#- "e'& 'a9 te#t!#$a mem'a#%#-a# me#!r!t e"omo !sa "om'a $at! e"omo !sa 5  6; '!"a# %a# e"omo !sa 6  = ta&!#.


(

SKALA PERKEMBANGAN BALITA USIA 6 BULAN # $ BULAN !5 HARI

0. 6. +. ;. =. 5. . >. 2. 0,. 00. 06. 0+. 0;. 0=.

NILAI

D!%! ta#a 'a#t!a#9 m#ma" + me#t Mera#-a Daat teta 'er%r /a %'a#t! 'er%r Mam! me#--e#--am ses!at! a%a seta ta#-a# Mem#%a&a# 'e#%a %ar sat! ta#-a# e ta#-a# "a# Me#/et ses!at! %e#-a# '! /ar %a# te"!#/! Me#-am'" %a# me"emar 'e#%a9 se#a#- a%a e-ata# $a#- %"asa#aa# 'er!"a#-
J!m"a& tem a%a re#ta#- !sa # a%a"a& 0= tem

J!m"a& N"a

USIA $ BULAN !6 Ha%i # !2 BULAN !5 HARI

05. 0. 0>. 02. 6,. 60. 66. 6+. 6;. 6=. 65. 6. 6>. 62. +,.

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NILAI

Daat 'er%r se#%r Daat 'er/a"a# %e#-a# %t!#t!# Daat mem'!#-! Me#-ara&a# a#%a#-a##$a !#t! me#ar ora#- $a#- sa#-at %e#a"#$a9 /a %ta#$a9 msa"#$a : Ma#a Baa F Me#o'a me#r!a# ata ata! s!ara $a#- 'ar! %%e#-ar#$a Be"a/ar me#-!aa# 6<+ ata ( MaF9 PaF) Me#r! t#-a& "a! se%er&a#a9 msa"#$a Me#ma#- 'o#ea#$aF I#-# mera& ata! me#$e#t!& se-a"a ses!at! %a# memas!a##$a e m!"!t Mem!!"

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J!m"a& N"a


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)

USIA !2 BULAN !6 Ha%i # !5 BULAN !5 HARI

+0. +6. ++. +;. +=. +5. +. +>. +2. ;,. ;0. ;6. ;+. ;;. ;=.

NILAI

Ber/a"a# se#%r9 me#/e"a/a& r!ma& me#-ert er#ta& se%er&a#a ata! "ara#-a#9 msa"#$a ('era# se#%o t! a%a '!F) M!"a me#-ert erta#$aa# se%er&a#a Me#-s -e"as %e#-a# 'e#%a<'e#%a e" Daat me#--e"#%#-a# 'o"a e ara& ora#- "a# Mem'a#t! me"easa# 'a/!9 msa"#$a me#-e"!ara# ta#-a# %ar " !'a#- ta#-a# 'a/! Daat 'er"ar9 mes 'e"!m sta'" Mem#ta ses!at! a%a ora#- "a# %e#-a# mera& ata! me#%eat 'e#%a $a#- %#-#a# Me#!#/!a# ma#a# ata! 'e#%a $a#- %e-a#-#$a a%a ora#- "a# Me#!#/!a# rasa mara& '"a e#-#a##$a t%a %aat tere#!& M!"a me#--!#aa# se#%o !#t! maa# Me#!#/!a# m#at "e'& /a!& ter&a%a ses!at! $a#- %ma#a##$a Me"am'aa# ta#-a# a%a ora#- $a#- aa# er- Memas!a# ata! me#-e"!ara# ma#a# %ar ota Me#ar ata! 'er-era eta me#%e#-ara# m!s


J!m"a& N"a

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USIA !5 BULAN !6 Ha%i # !" BULAN !5 HARI

NILAI

Bsa me#$ataa# #-# '!a#- ar 'esar M#!m se#%r %ar a#-r 'ere-a#-a# Me#!r!t er#ta& se%er&a#a seert : Fa$oF9 F%!%! s#F9 Fam'" 'o"a#$aF Me#--e#--am #s" %a# mem'!at oret<oreta# Me#-!aa# +<; ata se%er&a#a (maF9 mF9 #%aF9 %s') Memer"&ata# rasa se#a#- %e#-a# meme"! ata! me#!m ora#-t!a#$a Daat mem'!a aos a ta se#%r T%a se#a#- ata! mara& '"a %"ara#Se#a#- me"&at -am'ar<-am'ar %ar '!! Me#!#/!a# ata! me#$e'!ta# 'e#%a<'e#%a $a#- sa#-at %e#a"#$a Me#o'a me#e#%a#- 'o"a Me#-e#a" %r#$a %erm# Me#-e#a" 'e#%a<'e#%a $a#- 'ar! %"&at t a#a memas!a##$a e %a"am m!"!t Daat me#!#/!a# sa"a& sat! 'a-a# t!'!&#$a9 msa"#$a %ta#$a Fma#a am!F9 Fmatam!F 5,. Me#!m! 6<+ 'a"o e atas (me#erma %a# me#$!s!#)

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;5. ;. ;>. ;2. =,. =0. =6. =+. =;. ==. =5. =. =>. =2.

J!m"a& N"a


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*

USIA !" BULAN !6 Ha%i # 2! BULAN !5 HARI

50. 56. 5+. 5;. 5=. 55. 5. 5>. 52. ,. 0. 6. +. ;. =.

NILAI

Ber/a"a# mem'a7a 'e#%a 'esar $a#- r#-a# (ota ata! a"e#- oso#-) Daat mem'!a aos a#$a se#%r Na t!r!# ta#--a %e#-a# 'a#t!a# Me#!m! +<= !'!s e atas Me#!#/!a# + 'a-a# !t!& $a#- %se'!t ora#- "a# msa" : Fma#a matam!F9 Fma#a ram'!tm!F Me#$e'!t #ama#$a se#%r Be"a/ar maa# se#%r Geraa# saat 'er/a"a# ata! me#-am'" ses!at! s!%a& m!"a tere#%a" %a# terara& Tertar a%a &a"<&a" $a#- %"a!a# ora#- %e7asa9 msa"#$a me#$a! Me#!#/!a# ata! me#$e'!ta# 'e#%a<'e#%a $a#- sa#-at %e#a" Daat me"emar 'o"a Daat me#-!#$a& maa#a# %e#-a# 'a Mem'!a %a# me#!t! tas %e#-a# a##- tar (rts"et#-) Me#!#/!a# 'er'a-a maam erasaa# (se#a#-9 se%&9 mara&9 ee7a9 %s') M!"a mem'e#t! a"mat se%er&a#a (ter%r %ar 6 ata)


J!m"a& N"a

USIA 2! BULAN !6 Ha%i # 24 BULAN !5 HARI

5. . >. 2. >,. >0. >6. >+. >;. >=. >5. >. >>. >2. 2,.

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NILAI

Mem'!at -ars "!r!s % ertas9 ta#a& ata! asr Me#!#/!a# = 'a-a# t!'!& $a#- %ta#$aa# Bsa memaa sa#%a" se#%r Bsa me#! %a# me#-er#-a# ta#-a##$a se#%r Me"asa#aa# #str!s : mas!a# 'o"a # e %a"am otaF ata!  mas!a# se#%o t! e %a"am -e"asF Me#$e'!ta# #ama + 'e#%a $a#- %t!#/!a# ea%a#$a. T!#/!a# 'o"a9 "a"! ta#$aa# aa #F9 %a# seter!s#$a !#t! + 'e#%a $a#- a%a %setar#$a Ser#- me#a#$aa# ata! me#ar F%ma#a  '!F9 a$a& ata! e#-as!&#$a 'era%a Daat me#-em!aa# e#-#a##$a %e#-a# ata<ata mes %e#-a# t%a sem!r#a9 ta 'sa %a&am. Daat me#$e'!ta# aa $a#- %er/aa# ora#-9 msa"#$a me#$a!9 memasa Daat mem'!a ata! me#-!as sa#Me#-e#a" s!ara '#ata#- (msa"#$a : Fmeo#-F4!#-) Me#r! me#$e'!ta# #ama %ar ; 'e#%a ms"a#$a : 'o"a9 !rs9 e#s"9 'a/! (Ft!#/!a# 'e#%a terse'!t %a# se'!ta# #ama#$aF) Me#o'a me"emar %temat Ber#$a#$ %e#-a# me#-e"!ara# 'e'eraa ata Me#-e#a" 'e#%a<'e#%a %e#-a# me"&at -am'ar9 Msa"#$a : -am'ar '#ata#-9 '!a&<'!a&a# %a# "a#<"a#


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USIA 24 BULAN !6 Ha%i # &6 BULAN !5 HARI

NILAI

20. Daat me"omat % temat 26. Be"a/ar me"omat ses!at! se"e'ar 6= m %e#-a# ara me"a#-a&#$a 2+. Me#$!s!# /em'ata# %e#-a# + !'!s1'a"o e" 2;. M!"a 'erma# 'ersama a#a "a# 2=. Mem'!at -am'ar "#-ara# (me#r!)9 7a"a!!# 'e"!m sem!r#a 25. Me"emar 'o"a %ar atas ea"a me#!/! s!at! sasara# !ra#- "e'& 0 meter % &a%aa##$a 2. Me#$e'!t #ama  o'/e atas %asar #str!s (F# saaF) 2>. M!"a 'a#$a me#--!#aa# ata Fsa$aF ata! Fa!F 22. Be"a/ar te#ta#- o#se em"a# msa"#$a : t!#/!a# ma#a##$a9 ta#$aa# !#$a saa 0,,. Me#-e#a" ; 'e#%a %a# e#--!#aa# ata! !#-s#$a9 msa"#$a : "etaa# 'e'eraa 'e#%a % &a%aa##$a9 em!%a# ta#$aa# ma#a $a#- !#t! m#!m9 ma#a $a#- !#t! memoto#-9 ma#a $a#- !#t! mem'e" em'a#- -!"a1erme#9 ma#a $a#- !#t! %aa % a 0,0. Daat meertaa# e#-a"ama# %e#-a# se%er&a#a 0,6. Daat me#-e#aa# 'a/! 1 e"a#a %e#-a# 'a#t!a# 0,+. Daat me#-e#a" 'a&a$a seert 'e#%a ta/am9 ea&a# aa9 ta#--a9 '#ata#- me#---t9 %"" 0,;. Me#!#/!a# rasa mem" $a#- !at9 msa"#$a t%a me#-/#a# 'ara#-1ma#a##$a %#/am 0,=. Me#-e#a" 7ar#a %asar mera& 0,5. Daat me#o'a me#$a#$ 'ersama 0,. Me#ar me#-!t rama "a-!1m!s 0,>. Daat me#-!#ta ma#
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J!m"a& tem a%a re#ta#- !sa # a%a"a& 0> tem

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USIA &6 BULAN !6 Ha%i # 4" BULAN !5 HARI

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NILAI

0,2. Daat 'er/a"a# /#/t 'er%asara# #str!s 00,. Daat 'er/a"a# me#t 'a"o se"e'ar 6= m se'a#$a +<= "a#-a& 000. Me#-e#a" 6<; 7ar#a %asar 006. Ber#sat m!"a 'ere#a"a# ata! 'erma# %e#-a# a#a se'a$a 00+. Ma! me#%e#-ara# erta m#m!m 0, me#t 00;. Me#-e#a" ara& atas9 'a7a&9 %ea# %a# 'e"aa#00=. Daat me#r!a# -am'ar ora#- se%er&a#a %e#-a# ea"a %a# 'a%a# 'er'e#t! "#-ara# 005. Daat me"omat %e#-a# sat! a 00. Daat me#$e'!ta# /e#s e"am##$a se#%r 00>. Daat me#ertaa# e#-a"ama# %e#-a# !! " a#ar 002. Daat me#-a##- 'a/! se#%r 06,. Daat maa# se#%r 060. Daat me#$a#$ se#%r 066. M!"a 'a#$a 'erta#$a 06+. Daat me#e%a#- %a# me"emar 'o"a %e#-a# /ara !ra#- "e'& 69=  + meter 06;. Daat me#-&t!#- 6<+ 'e#%a 06=. Daat me"at ertas %e#-a# !! ra 065. Daat me7ar#a9 ta#a 'a#$a e"!ar -ars 'atas

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USIA 4" BULAN !6 Ha%i # 6' BULAN !5 HARI

06. Daat me#-&t!#- = 'e#%a 06>. Me#-eta&! /!m"a& /ar ta#-a# 062. Daat me#$e'!ta# #ama '! /ar1/emo" 0+,. Daat me#$a#$a# m#ma" 6 "a-! se%er&a#a 0+0. Daat me#--am'ar ora#- %e#-a# 'a-a# ea"a9 'a%a# %a# a#-ota 'a%a# (ta#-a# %a# a) 0+6. Daat me#$e'!ta# a#-a 0<0, seara 'er!r!ta# Sumber : Yayasan Kesejahteraan Anak Indonesia, 1997, Di ketik ulang oleh Manjilala htt!:""gi#imu$%om&

NILAI

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0++. Daat me#$e'!ta# rasa -!"a %a# -aram 0+;. Daat me"a!a# ; er#ta& se%er&a#a seara 'er!r!ta# msa"#$a : t!t!a# #t!9 "a"! am'"a# -e"as9 sa# ar e %a"am#$a %a# 'a7a emar 0+=. Daat 'erma# 'ersama %e#-a# tema# %a# 'er'a-a era# 0+5. Daat mem'e%aa# !!ra# 'esar %a# e" 0+. Me#-e#a" ;<= 7ar#a 0+>. Daat me#-e"omoa# 'e#%a $a#- 'er'e#t! sama msa"#$a : se%aa# 'e'eraa a##-9 e"ere#-9 '/ sa7o ata! era#-. Cam!ra# a%! /a% sat!9 "a"! m#ta a#a me#-!m!"a# $a#- sama me#/a% sat! e"omo 0+2. Me#-#-at "eta + 'e#%a seara 'er!r!ta#9 "etaa# + 'e#%a e"9 msa"#$a e"ere#-9 !'!s %a# ma#a# e". T!#/!a# "eta#$a a%a a#a9 m#ta a !#t! me#-#-at#$a. La"! t!t! mas#-
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USIA 6' BULAN !6 Ha%i # 2 BULAN !5 HARI

NILAI

0;=. Daat me#a#-a 'o"a $a#- %"emara# %ar /ara 0 meter %e#-a# teat 0;5. Me#-eta&! ara mema#/at o&o#1a"a#- 'et#-at 0;. Daat mem'e%aa# r<a#a#9 %ea#<'e"aa#-9 atas<'a7a& 0;>. Daat me#--am'ar ma#!sa seara "e#-a 0;2. Daat ma# "omat ta" %e#-a# a %a#-at 'er-a#t<-a#t 0=,. Mem'!at 'e#t! -eometrs seert se-t-a9 se-emat9 "#-ara# 0=0. Berta#$a %e#-a# me#--!#aa# ata ta#$a : e#aa9 aa#9 'a-ama#a9 %s' 0=6. Me#$at -- ta#a %'a#t! 0=+. Me#ertaa# te#ta#- e"!ar-a (#ama ora#- t!a9 a"amat) 0=;. Me#ertaa# em'a" s erta %ar '!! erta 'er-am'ar 0==. Ber&t!#- a#-a sama 0, 0=5. Daat me#--!#t#- 'e#t! "#-ara#9 se-emat %a# se-t-a 0=. Me#!"sa# #ama#$a se#%r 0=>. Me#-!t erma#a# $a#- 'ersat omett %e#-a# at!ra# (eta !met9 a%! "ar) 0=2. Me#-er/aa# t!-as
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FORMULIR PENILAIAN PSIKOLOGI LOMBA BALITA SEHAT.pdf

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