KUESIONER SURVEY PENYELIDIKAN EPIDEMIOLOGI PENYAKIT KECACINGAN DIWILAYAH KERJA PUSKESMAS ........................... TAHUN TAHUN 2016 201 6
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IDENTITAS RE RESPONDEN Nama : Umu : J!"#$ K!%am#" : P!&!'aa" : P!"(#(#&a" T!a&)# T!a&)# : ETIOLOGI PENYAKIT 1. P!"* P!"*a& a&#+ #+ *a", a", (#(! (#(!# #+a +a 2. Lama $a&#+ -. K"(#$# /! /!"(!#+a $a $aa+ (# (#$u!* . P!",a+a" *a", (#'a%a"# 3. T!m/a+ !a+ 6. Ha$#% /!m!#&$aa"
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PERI PERILA LAKU KU KESE KESEHA HAT TAN A. PENG PENGET ETA AHUAN HUAN 1. A/a&a A/a&a) ) a"(a a"(a +a)u +a)u /!"*a /!"*a&#+ &#+ &!4a4#", &!4a4#",a" a" (#$!a&a (#$!a&a" " %!) %!) ma$u&" ma$u&"*a *a +!%u 4a4#", 4a4#", 5$!/! 5$!/!+# +# A$4a# A$4a#$$ %um# %um#4# 4#(!$ (!$ O7*u# O7*u#$$ !m#4 !m#4u%a u%a#$ #$ Ta!"#a a!"#a$#$ $#$ (a" %a#"8%a %a#"8%a#"9 #"9 &!(a%am +uu) a. Ta)u . Ra,u8a,u 4. T#(a& +a)u 2. A/a& A/a&a) a) a"(a a"(a +a)u +a)u /!"* /!"*a& a&#+ #+ &!4a &!4a4# 4#", ",a" a" (a/a (a/a++ m!"* m!"*! !a a&a &a" " &!&u &!&ua a", ",a" a" ,#;# ,#;# m!"uu""*a (a*a +a)a" +uu) (a" m!"#mu%&a" ,a",,ua" /a(a +umu) &!ma", /!"(!#+a a. Ta)u . Ra,u8a,u 4. T#(a& +a)u -. A/a&a) A/a&a) a"(a +a)u +a)u &uu$ &uu$ mua% mua% %!ma$ "a<$u "a<$u ma&a" ma&a" !&ua", !&ua", (#a! (#a! /!u+ /!u+ $!#", $a&#+ (a" u"4# m!u/a&a" ,!'a%a /!"*a&#+ &!4a4#",a" a. Ta)u . Ra,u8a,u 4. T#(a& +a)u
. A/a&a) a"(a +a)u 4aa /!"u%aa" /!"*a&#+ 4a4#",a" (a/a+ m!%a%u# &"$um$# ma&a"a" a+au m#"uma" *a", +!&+am#"a$# 4a4#", (a" +a",a" a+au &a&# *a", &+ a. Ta)u . Ra,u8a,u 4. T#(a& +a)u 3. A/a&a) a"(a +a)u &"+a& (!",a" +a"a) *a", +!&"+am#"a$# (!",a" &+a" ma"u$#a (a/a+ m!"*!a&a" /!"*a&#+ &!4a4#",a" a. Ta)u . Ra,u8a,u 4. T#(a& +a)u 6. A/a&a) a"(a +a)u ua", a# !$a 5>A>9 (#$!maa", +!m/a+ 5$u",a# &!u"9 (a/a+ m!"*!a&a" %#",&u",a" *a", &+ (a" m!"#mu&a" /!"*a&#+ 4a4#",a" a. Ta)u . Ra,u8a,u 4. T#(a& +a)u ?. A/a&a) a"(a +a)u /!"*a&#+ &!4a4#",a" (a/a+ (#a+# (!",a" m!",&"$um$# a+ $!/!+# m!!"(a;% a%!"(a;%! (a" /#a"+!% /ama+ a. Ta)u . Ra,u8a,u 4. T#(a& +a)u @. A/a&a) a"(a +a)u m!"4u4# +a",a" (!",a" $au" $!!%um ma&a" (a" $!$u(a) &!%ua (a# &ama ma"(# 5>A>9 (a/a+ m!"4!,a) +!'a(# /!"*a&#+ &!4a4#",a" a. Ta)u . Ra,u8a,u 4. T#(a& +a)u >. SIKAP 1. A/a&a) a"(a !$!(#a m!",&"$um$# ma&a"a" *a", (#$#a/&a" (!",a" $a"#+a$# a+au &!!$#)a" *a", m!ma(a# a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a 2.
A/a&a) a"(a !$!(#a m!"4u4# +a",a" (!",a" $au" $!!%um ma&a" (a" $!+!%a) &!%ua (a# &ama ma"(# a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a
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A/a&a) a"(a !$!(#a m!"'a,a &!!$#)a" &u&u (!",a" m!m+", &u&u $a+u m#",,u $!&a%#
a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a .
A/a&a) a"(a !$!(#a m!"'a,a &!!$#)a" &a&# (!",a" m!ma&a# a%a$ &a&# $aa+
(#(a%am mau/u" (#%ua uma) a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a 3. A/a&a) a"(a !$!(#a m!"*!(#a&a" +!m/a+ /!mua",a" &+a" *a", m!m!"u)# $*aa+ (a" +#(a& m!"4!ma# +a"a) a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a 6.
A/a&a) a"(a !$!(#a m!",,,u"a&a" a# !$#) *a", m!m!"u)# $*aa+ u"+u& &!u+u)a" )#(u/ $!)a#8)a# a. >!$!(#a . Ra,u a,u 4. T#(a& !$!(#a
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C. TINDAKAN 1. A/a&a) a"(a m!",&"$um$# ma&a"a" *a", (#$#a/&a" (!",a" $a"#+a$# a+au &!!$#)a" *a", m!ma(a# a. Ya . Ka(a", &a(a", 4. T#(a& 2.
A/a&a) a"(a m!"4u4# +a",a" (!",a" $au" $!!%um ma&a" (a" $!+!%a) &!%ua (a# &ama ma"(# a. Ya . Ka(a", &a(a", 4. T#(a&
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a. Ya . Ka(a", &a(a", 4. T#(a& .
A/a&a) a"(a m!"'a,a &!!$#)a" &a&# (!",a" m!ma&a# a%a$ &a&# $aa+ (#(a%am mau/u" (#%ua uma) a. Ya . Ka(a", &a(a", 4. T#(a&
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A/a&a) a"(a m!m!#&$a&a" &!$!)a+a" a"(a &! (&+! $!4aa !&a%a /!#)a% &!4a4#",a" a. Ya . Ka(a", &a(a", 4. T#(a&
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A/a&a) a"(a m!m#"um a+ 4a4#",a" 6 u%a" $!&a%# $!4aa +!a+u a. Ya . Ka(a", &a(a", 4. T#(a&
LEM>AR O>SERVASI N. 1.
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a+au &!!$#)a" *a", m!ma(a#. M!"4u4# +a",a" (!",a" $au" $!!%um ma&a" (a"
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$!+!%a) &!%ua (a# &ama ma"(#. Ku&u (a%am &!a(aa" !$#) (a" /!"(!&. M!ma&a# a%a$ &a&# $aa+ (#(a%am mau/u" (#%ua uma). M!"*!(#a&a" +!m/a+ /!mua",a" &+a" *a", m!m!"u)# $*aa+ (a" +#(a& m!"4!ma# +a"a).
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M!",,,u"a&a" a# !$#) *a", m!m!"u)# $*aa+ u"+u&
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BORMULIR PENILAIAN SANITASI FORMULIR PENILAIAN SANITASI
DESA KECAMATAN KA>UPATENKOTA PROPINSI NAMA SURVEYER TANGGAL
: : KAWEDANAN : MAGETAN : JAWA TIMUR : : NOVEM>ER 2016
NO. KOMPONEN YANG DINILAI I. P!uma) S!)a+ 1. K!!$#)a" %#",&u",a"
KRITERIA
a. Ha%ama" !$#) +#(a& !4!& . Ha%ama" &+ +#(a& !4!&
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1 II. 1.
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Saa"a SPAL Sa%ua" P!mua",a" L#ma) Ruma) Ta",,a
Saa"a P!mua",a" Sam/a) T!m/a+ Sam/a)
a. A(a (#ua", (#$!%&a" +!+u+u/ +#(a& a(a ,!"a",a" !$#) . A(a (#ua", (#$!%&a" +!u&a &+ 4. T#(a& a(a a(a ,!"a",a" &+
a. A(a &!(a/ a# +!+u+u/ . A(a +#(a& &!(a/ a# +!+u+u/ +!u&a 4. T#(a& a(a
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1 IV. 1.
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A# >!$#) A# !$#) *a", (#,u"a&a"
P!mua",a" T#"'a P!mua",a" +#"'a *a", (#,u"a&a" (# uma)
a. Sum! PDAM &ua"+#+a$ (a" &ua%#+a$ m!m!"u)# $*aa+ . Sum! PDAM &ua"+#+a$ (a" &ua%#+a$ +#(a& m!m!"u)# $*aa+ 4. Sum! (a# $umu ,a%# $u",a# (a" $!'!"#$"*a
a. A(a m(!% %!)! a",$a +!+u+u/ . A(a m(!% 4!m/%u", +#(a& +!+u+u/ 4. T#(a& a(a
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H#,#!"! P!a",a" H#,#!"! /!a",a"
a. M!",,u"a&a" a%a$ &a&# 4u4# +a",a" m!m+", &u&u &u&u
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