KUESIONER SURVEY PERILAKU HIDUP BERSIH DAN SEHAT (PHBS) DI SEKOLAH NAMA SEKOLAH
: __ ________________________________
A L A M A T
: Desa Kecamatan
JUMLAH SISA
: La!"#La!" Pe%em'an
: ________________ ________________ : ________________ : _______ $%an& : _______ $%an&
JUMLAH DOKTER KEIL * KKR
: _______ $%an&
+URU YAN+ SUDAH DILATIH UKS
: _______ $%an&
RUAN+AN UKS
: a,a * t",a! a,a -)
TAN++AL SURVEY
: ________________
INDIKATOR PHBS SEKOLAH No
Uraian Indikator PHBS
.
Mencuci Tangan dengan Air Bersi !ang Menga"ir dan Me#akai Sa$un a/ Sema Sema !e0as !e0as mem"0"!" mem"0"!" sa%ana sa%ana cc" cc" tan&an tan&an ,"0en&!a'" sa1n 1/ Sem Sema a s"s2 s"s2a a se0a se0a0 0 me0a me0a! !!a !an n cc" cc" tan& tan&an an 'a!a 'a!a"" sa1 sa1n n ,"se ,"se!$ !$0a 0a3 3 (se1 (se1e0 e0m m ma!a ma!an4 n4 sete0a3 BAB ata set"a' tan&an !$t$%) Mengkonsu#si %a%anan seat dikantin seko"a a/ Se!$0a Se!$0a3 3 mem"0" mem"0"!" !" !ant" !ant"n n 1/ Kant"n Kant"n se!$0a se!$0a3 3 men6e,"a men6e,"a!a !an n ma!ana ma!anan n tan'a 'en&a2et ,an se0a0 te%tt' se3"n&&a t",a! ,"3"n&&a'" 0a0at c/ Sem Sema a s"s2 s"s2a a mem1 mem1e0 e0"" ,an ,an men& men&!$ !$ns nsm ms" s" 7a7anan 6an& ,"se,"a!an ,"se,"a!an ," !ant"n se!$0a3 Menggunakan %a#$an !ang $ersi dan seat a/ Se!$0a3 Se!$0a3 mem"0"! mem"0"!"" 7am1an 7am1an sesa" sesa" ,en&an ,en&an %at"$ %at"$ 7m0a3 s"s2a 1/ Jam1an Jam1an se!$ se!$0a3 0a3 te%'e0 te%'e0"3a "3a%a %a (1e%s"3 (1e%s"3 ,an ,an t",a! 1e%1a) c/ Sem Sema a s"s2 s"s2a a men& men&& &na na!a !an n 7am1 7am1an an nt nt! ! BAB ," se!$0a3 O"araga !ang teratur dan terukur Sema s"s2a me0a!!an a!t""tas ;"s"! ($0a3%a&a) ,en&an 2a!t ,an 7a,2a0 6an& ,"tent!an/ (a,a !e&"atan senam se1e0m m0a" 1e0a7a% ,an ata mas"n&#mas"n& s"s2a mem"0"!" 7a,2a0 'e0a7a%an $0a3%a&a set"a' m"n&&) Me#$erantas %entik n!a#uk A,a !e&"atan se!$0a3 se!$0a3 (s"s2a ,an &%) set"a' m"n&&4 nt! mem1e%s"3!an 1a! man," ,an 'enam'n&an a"% 0a"nn6a4 ment' 'enam1n&an a"% ,an men&1% 1a%an& 1e!as
5
8
9
<
Ya
Tidak
Ket
No
Uraian Indikator PHBS
=
Tidak #erokok diseko"a T",a! a,a s"s2a ,an &% me%$!$! ," 0"n&!n&an se!$0a3 set"a' 3a%" Meni#$ang $erat $adan dan #engukur tinggi $adan A,a !e&"atan s"s2a nt! men"m1an& 1e%at 1a,an ,an men&!% t"n&&" 1a,an ,"%an& UKS m"n"ma0 = 10an se!a0" Me#$uang sa#&a &ada te#&atn!a a/ Sem Sema a !e0a !e0as s mem" mem"0"! 0"!"" tem' tem'at at 'ena 'enam' m'n n&a &an n sam'a3 sementa%a (1a! sam'a3) 1/ Sema Sema s"s2a s"s2a ,an ,an &% se0a0 se0a0 1an& 1an& sam'a sam'a3 3 'a,a tem'at sam'a3 (1a! sam'a3)
>
?
Ya
Tidak
Ket
TOTAL SKOR
/////////////////4 ////////////////////////////////// Pet&as S%e6
( _____________________ _____________________ )
K%"te%"a K0as";"!as" PHBS se!$0a3 : ./ Se!$0a Se!$0a3 3 Se3at Se3at (K0as" (K0as";"! ;"!as" as" B"%)4 B"%)4 B"0a B"0a sema sema "n,"!at$ "n,"!at$%% PHBS PHBS Se!$0a Se!$0a3 3 (? "n,"!at$ "n,"!at$% % te%'en3" ata ,"7a2a1 @YA) @YA) 5/ Se!$0a3 Se!$0a3 K0as";"!as K0as";"!as"" H"7a4 B"0a "n,"!at$% "n,"!at$% PHBS 6an& 6an& te%'en3" te%'en3" (,"7a2a1 (,"7a2a1 @YA) @YA) anta%a = > "n,"!at$%/ 8/ Se!$0a3 Se!$0a3 K0as";"!as K0as";"!as"" Kn"n&4 B"0a "n,"!at$% "n,"!at$% PHBS 6an& 6an& te%'en3" te%'en3" (,"7a2a1 (,"7a2a1 @YA) @YA) anta%a 9 < "n,"!at$%/ 9/ Se!$0a3 Se!$0a3 K0as";"!as K0as";"!as"" Me%a34 B"0a "n,"!at$% "n,"!at$% PHBS 6an& 6an& te%'en3" te%'en3" (,"7a2a1 (,"7a2a1 @YA) @YA) anta%a .#8 "n,"!at$%/
PENJELASAN INDIKATOR DAN PEN+ISIAN KUESIONER N$
In,"!at
%$De;"n"s" O'e%as"$na0
Pemen3an In,"!at$%
Kete%an&an
.
Mencc" Tan&an ,en&an A"% Be%s"3 6an& Men&a0"% ,an Mema!a" Sa1n
Se!$0 !$0a3 6an& an& ,"!a "!ata!a ta!an n memen memen3" 3" "n,"!at$ "n,"!at$%% Mencc" Mencc" Tan&an n&an ,en& ,en&an an A"% Be%s Be%s"3 "3 6an& 6an& Men&a0" Men&a0"%% ,an Mema!a" Mema!a" Sa1n a,a0a3 se!$0a3 6an& : a/ mem"0"!" sa%ana cc" tan& tan&an an 6an& 6an& ,"0e ,"0en& n&!a !a'" '" ,en&an sa1n 1/ sem sema a s"s2 s"s2an an6a 6a mem" mem"0" 0"!" !" !e1" !e1"as asaa aan n cc" cc" tan& tan&an an men&&na!an a"% men&a0"% ,an sa1n se1e0m ma!an4 sete0a3 BAB ata set"a' tan&an !$t$%/
se!$ se!$0a 0a3 3 meme memen n3" 3" "n,"!at$% "n,"!at$%44 1"0a !e,a !e,a "tem 'e%tan6aan (a ,an 1) ,"7a2 "7a2a1 a1 @YA
Data ,"'e%$0e3 ,en&an 'en&amatan !e1e%a,aan sa%ana cc" tan&an ,"set"a' !e0as ,an menan6a!an !e'a,a &% ,an s"s2a ," mas"n&# mas"n& !e0as tentan& !e1"asaan cc" tan&an
5
Men&!$nsms" 7a7anan se3at se3at ," !ant"n se!$0a3
Se!$0 !$0a3 6an& mem memen3" "n,"!a "!at$% t$% men men&!$n !$nsms sms"" 7a7anan se3at ," !ant"n se!$0a3 a,a0a3 se!$0a3 6an& : a/ mem"0"!" !ant"n 6an& men6 men6e, e,"a "a!a !an n ma!a ma!ana nan n se3a se3att tan' tan'a a 'en& 'en&a2 a2et et ata'n 'e2a%na 1e%1a3a6a ,an men6 men6a a7"!a 7"!an n ma!ana anan ,en&an aman 'a,a 2a,a3 6an& 1e%s"3 ,an te%tt' 1/ s"s2 s"s2an an6a 6a men& men&!$ !$ns nsm ms" s" ma!a ma!ana nan n 6an& 6an& se3a se3att ," !ant"n se!$0a3/
Se!$0a Se!$0a3 3 meme memen n3" 3" "n,"!at$% "n,"!at$%44 1"0a !e,a !e,a "tem 'e%tan6aan (a ,an 1) ,"7a2 "7a2a1 a1 @YA
Data ,"'e%$0e3 ,en&an 'en&amatan !e1e%a,aan !ant"n ,an 'en6a7"an ma!anan ," !ant"n se!$0a3 ,an menan6a!an !e'a,a &%4 'en&e0$0a !ant"n ,an s"s2a tentan& !e1"asaan 7a7anan ,"se!$0a3
8
Men&&na!an 7am1an 6an& 6an& 1e%s"3 ,an se3at
Se!$0 !$0a3 6an& mem memen3" "n,"!at$% men&&na!an 7am1an 6an& 1e%s"3 ,an se3at a,a0a3 se!$0a3 6an& : a/ Se!$ Se!$0a 0a3 3 mem" mem"0" 0"!" !" 7am1 7am1an an sesa" ,en&an %at"$ 7m0a3 s"s2a 1/ Jam1an se!$0a3 te%' te%'e0 e0"3 "3a% a%a a (1e% (1e%s" s"3 3 ,an ,an t",a! 1e%1a) c/ Sema s"s2a men& men&& &na na!a !an n 7am1 7am1an an nt! BAB ," se!$0a3
Se!$0a Se!$0a3 3 "n,"!at$% "n,"!at$%44 "tem (a4 1 ,an @YA
Data ,"'e%$0e3 ,en&an 'en&amatan !$n,"s" 7am1an se!$0a3 ,an menan6a!an !e'a,a &%4 ,an s"s2a tentan& !e1"asaan BAB s"s2a ,"se!$0a3
9
O0a3%a&a 6a 6an& te%at% ,an te%!%
Se!$0 !$0a3 6an& mem memen3" Se!$0a3 memen3" "n,"!at$% $0a3%a&a 6an& te%at% "n,"!at$%4 1"0a "tem ,an ,an te%! te%!%% a,a0a a,a0a3 3 se!$0a se!$0a3 3 'e%tan6aan te%'en3" 6an& 6an& s"s2 s"s2an an6a 6a me0a me0a! !!a !an n ata ,"7a2a1 @YA a!t" !t"""tas tas ;"s" ;"s"! ! ($0a $0a3%a&a) a&a) ,en&a en&an n 2a!t a!t ,an ,an 7a,2 7a,2a0 a0 6an& 6an& ,"ten ,"tent! t!an an se'e% se'e%t" t" a,a a,a !e&" !e&"at atan an sena senam m se1e se1e0 0m m m0a" 1e0a7a% ,an ata mas"n&#mas"n& s"s2a mem"0"!" 7a,2a0 'e0a7a%an 'e0a7a%an $0a3%a&a $0a3%a&a set"a' m"n&&/
meme memen n3" 3" 1"0a !et"&a !et"&a 'e%tan6aan c) ,"7a2a1
Data ,"'e%$0e3 ,en&an menan6a!an !e'a,a &% ,an s"s2a tentan& 7a,2a0 $0a3%a&a $0a3%a&a ,"se!$0a3
N$
In,"!at
%$De;"n"s" O'e%as"$na0
Pemen3an In,"!at$%
Kete%an&an
<
Mem1e%antas 7e 7ent"! n6am!
Se!$0 !$0a3 6an& mem memen3" "n,"!at$ "n,"!at$%% mem1e%an mem1e%antas tas 7ent"! 7ent"! n6am! a,a0a3 se!$0a3 (s"s2a ,an ,an &% &%)) 6an& 6an& me0a me0a! !!a !an n !e&"ata !e&"atan n %t"n %t"n set"a' set"a' m"n&&4 m"n&&4 nt! nt! mem1 mem1e% e%s" s"3! 3!an an 1a! 1a! man," man," ,an 'enam' 'enam'n&an n&an a"% 0a"nn6a4 ment' 'enam1n&an a"% ,an men& men&1 1% % 1a%a 1a%an& n& 1e!a 1e!as s ," 0"n&!n&an se!$0a3/
Se!$0a Se!$0a3 3 meme memen n3" 3" "n," "n,"!a !at$ t$%%4 1"0a 1"0a "tem "tem 'e%tan6 'e%tan6aan aan te%se1 te%se1tt te%'en3" ata ,"7a2a1 @YA
Data ,"'e%$0e3 ,en&an menan6a!an !e'a,a &% ,an s"s2a tentan& !e&"atan 'em1e%antasan sa%an& n6am!
=
T",a! me%$!$! ,"se!$0a3
Se!$0 !$0a3 6an& mem memen3" "n,"!at$% t",a! me%$!$! ,"se ,"se!$ !$0a 0a3 3 a,a0a ,a0a3 3 se!$ se!$0a 0a3 3 ,en&an s"s2a ,an &% 6an& t",a! t",a! me%$!$! me%$!$! ," 0"n&!n 0"n&!n&an &an se!$0a3 set"a' 3a%"n6a/
Se!$0a Se!$0a3 3 meme memen n3" 3" "n," "n,"!a !at$ t$%%4 1"0a 1"0a "tem "tem 'e%tan6 'e%tan6aan aan te%se1 te%se1tt te%'en3" ata ,"7a2a1 @YA
Data ,"'e%$0e3 ,en&an menan6a!an !e'a,a &% ,an s"s2a tentan& !e1"asaan me%$!$! ,"se!$0a3
>
Men"m1an& 1e%at 1a,an ,an men&!% t"n&&" 1a,an
Se!$0 !$0a3 6an& mem memen3" "n,"! "n,"!at$ at$%% men"m men"m1a 1an& n& 1e%at 1e%at 1a,a 1a,an n ,an ,an men& men&! !%% t"n&& t"n&&"" 1a,a 1a,an n a,a0a a,a0a3 3 se!$0 se!$0a3 a3 6an& 6an& me0a!sana!an !e&"atan 'en"m1an&an 1e%at 1a,an ,an 'en& en&! !%a %an n t"n& t"n&&" &" 1a,a 1a,an n ,"%an& UKS m"n"ma0 = 10an se!a0"
Se!$0a Se!$0a3 3 meme memen n3" 3" "n," "n,"!a !at$ t$%%4 1"0a 1"0a "tem "tem 'e%tan6 'e%tan6aan aan te%se1 te%se1tt te%'en3" ata ,"7a2a1 @YA
Data ,"'e%$0e3 ,en&an 'en&amatan 'e%a0atan ,"%an& UKS ,an menan6a!an !e'a,a &% se%ta s"s2a tentan& !e&"atan 'en"m1an&an ,an 'en&!%an t"n&&" 1a,an ,"se!$0a3
?
Mem1an& sam'a3 'a,a tem'atn6a
Se!$0 !$0a3 6an& mem memen3" "n,"!at$ "n,"!at$%% mem1a mem1an& n& sam'a3 sam'a3 'a,a tem'atn6a a,a0a3 se!$0a3 6an& : a/ mem"0"!" tem'at 'enam'n& 'n&an an sam'a3 m'a3 semen sementa% ta%a a (1a! (1a! sam'a sam'a3) 3) ,"set"a' %an&an !e0as 1/ S"s2a ,an &% se0a0 1an& sam'a3 'a,a tem'at sam' sam'a3 a3 (1a! (1a! sam sam'a3) 'a3)44 se3"n&&a t",a! a,a sam'a3 1e%se 1e%se%a %a!a !an n ," 0"n&! 0"n&!n& n&an an se!$0a3
Se!$0a Se!$0a3 3 meme memen n3" 3" "n,"!at$% "n,"!at$%44 1"0a !e,a !e,a "tem 'e%tan6aan te%s te%se e1t 1t (a ,an ,an 1) ,"7a2a1 @YA
Data ,"'e%$0e3 ,en&an 'en&amatan !e1e%a,aan 1a! sam'a3 ," !e0as4 !e1e%s"3an 0"n&!n&an se!$0a3 ,an menan6a!an !e'a,a &% se%ta s"s2a tentan& !e1"asaan 1an& sam'a3
