KARTU JENTIK RUMAH/BANGUNAN*

Nama KK/Pengelola Bangunan/Instansi : …………………………………………………………………………………..

Alamat : ................................................................................................................................

Desa/Kelurahan : ..................................................................................................................

Kecamatan : .........................................................................................................................

Kabupaten/Kota : .................................................................................................................

BULAN Hasil pemeriksaan jentik nyamuk penular DBD ( + )/ (-)Tahun

2005 2006 2007 2008 2009 2010Minggu Minggu Minggu Minggu Minggu Minggu

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4JANUARI

FEBRUARIMARETAPRILMEIJUNI JULI

AGUSTUSSEPTEMBER

OKTOBERNOVEMBERDESEMBER

*gantungkan pada meteran listrik rumah/bangunan

Petugas pemeriksa jentik

(.....................................................................)

Formulir JPJ-1

HASIL PEMERIKSAAN JENTIK

RT/ RW : ..................................................................................................

DESA/ KELURAHAN : ...............................................................................

KECAMATAN : .........................................................................................

KABUPATEN/KOTA : ...............................................................................

NO NAMA KK /JENIS/NAMA TTU

ALAMAT (RT/RW)

JENTIK KETERANGAN (+) (-)

Petugas pemeriksa jentik

(............................................................)