Lampiran Lap Akhir Rev Yankesling

8/16/2019 Lampiran Lap Akhir Rev Yankesling

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Lampiran 1.

KARTU PENGANTAR

PELAYANAN KESEHATAN LINGKUNGAN

DIAGNOSA

NAMA 1 DIARE

JENIS /KELAMIN 2 ISPA

UMUR 3 TB

ALAMAT 4 DEMAM BERDARAH DENGUE

5 MALARIA

TANGGAL 6 KULIT

PEMERIKSA/ PETUGAS LOKET

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

7 KECACINGAN

KERACUNAN PESTISIDA

! KERACUNAN MAKANAN

1" PEN#AKIT AKIBAT

PENCEMARAN

LINGKUNGAN/LINGKUNGANKERJA

11 ...................................

12

13

14

PERMASALAHAN$

Lampiran 2.


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PEMERINTAH DAERAH KABUPATEN/KOTA .......................

PUSKESMAS $ %%%%%%%%%%%%%%%%%%%%%%

KECAMATAN $ %%%%%%%%%%%%%%%%%%%%%%

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

KARTU STATUS KESEHATAN LINGKUNGAN

N'. I*+, $

N-- -,0*/+0* $ %%%%%%%%%%%%%%%%% N-- KK $ %%%%%%%%%%%%%%%%%%%%%

U $ %%%%%%%%%%%%%%%%%%%% ( -0/-/-)

J*0, K*-0 $ L-+0-+0/P**- 8)

A9-- $ %%%%%%%%%%%%%%%%

P*+*:-- $ %%%%%%%%%%%%%%%%

A-- $ %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

$ D, %%%%%%%%%%%%%%%%%%% RT/R; %%%%%%%%%%%%%%%%%%%

$ D*,- %%%%%%%%%%%%%%%%%%%%%%%%%

G''9- $ U/A,+*,/ -0-0 $ %%%%%%%%%%%%%%%%%%%%

T-99- A-*,-/-,-- T*-0/,-- K**-9-

J-:0 +:9- -/

'+-,0

T9 $ %%%%%%%%%%%

;-+ $%%%%%%%%%%%

L-0- 3.


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PUSKESMAS $ %%%%%%%%%%%%%%%%%%%%%%

KECAMATAN $ %%%%%%%%%%%%%%%%%%%%%%

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

LEMBAR SARAN/ REKOMENDASI

N-- < A--

P-,0*/K0*

A-*,-/-,-- T*-0/,-- K**-9-

J-:0 +:9- -/

'+-,0

T9 $ %%%%%%%%%%%

;-+ $%%%%%%%%%%%

T9 $

P*9-, P*-=-- K*,*-- L09+9-

(%%%%%%%%%%%%%%%%%)

L-0- 4.


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PUSKESMAS $ %%%%%%%%%%%%%%%%%%%%%%

KECAMATAN $ %%%%%%%%%%%%%%%%%%%%%%

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

REGISTRASI HARIAN KEGIATAN PELAYANAN KESEHATAN LINGKUNGAN

N' T9 N-- S*> U,0- A-- P/K M-,-- T*-0/ ,--

T9+:9-

-

H-,00-+

-:

K**-9-

K**-9- $ P $ P-,0*

K $ K0*

Lampiran 5.


5/9


PUSKESMAS $ %%%%%%%%%%%%%%%%%%%%%%

KECAMATAN $ %%%%%%%%%%%%%%%%%%%%%%

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

LAPORAN BULANAN KEGIATAN LAYANAN KESEHATAN LINGKUNGAN

BULAN $ %%%%%%%%%%%%%%%%

TAHUN $ %%%%%%%%%%%%%%%%

N' N--

*,-

J- P-,0* J- K0*K:9-

+*

#-+*,09

K:9-

-/

09+9-

O* *9-,

M*-+,-

-

+- ,--

K:9-

+*

#-+*,09

K:9-

-/

09+9-

O* *9-,

M*-+,--

+- ,--

J- '-

L-0- 6.


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PUSKESMAS $ %%%%%%%%%%%%%%%%%%%%%%

KECAMATAN $ %%%%%%%%%%%%%%%%%%%%%%

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

Laporan Pembangunan dan perba!an "arana !e"e#a$an %ng!unganKega$an Yan!e"%ng

N' N--

KK

P/K J*0,

P*=-+0

/

-,--

S---

,-0-,0/

09+9-

=-9

0-9/

0*-0+0

B--

S0-

S?--=-

-,=--+-

B0-=- J

P*-@--

K*

'.

M-*0-

H-9- J*0,/

'*

H-9-

K**-9- $ P/K & P-,0*/K0*

Lampiran 7.

LAPORAN TIGA BULANAN KEGIATAN PELAYANAN KESEHATAN LINGKUNGAN


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PROVINSI :...................................

KABUPATEN/KOTA $ ......................................

.

BULAN $ ............,/............

TAHUN $ %%%%%%%%%%%%%%%%

J- P,+*,-, $....................................................

J- P,+*,-, #-9 M*-++- K',*09 S*0- H-0 K*:- $.............................

J- P,+*,-, T0-+ M*-++- K',*09 S*0- H-0 K*:-$.............................

&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&

N' N--

P,+*,-,

J- P-,0* J- K0*

K:9-

+*

#-+*,09

K:9-

-/

09+9-

O*

*9-,

M*-+,-

-

+- ,--

K:9-

+*

#-+*,09

K:9-

-/

09+9-

O*

*9-,

M*-+,--

+- ,--

JML

Lampiran 8.

LAPORAN ENAM BULANAN KEGIATAN PELAYANAN KESEHATAN LINGKUNGAN


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PROVINSI :...................................

BULAN $ ............,/............

TAHUN $ %%%%%%%%%%%%%%%%

N' K-

K'-

J

P,+

J P,+

#-9

*-++-

+',*09

,*0- -0

+*:-

J

P,+

T0-+

*-++-

+',*09

,*0- -0

J- P-,0* J- K0*

K:9-

+* R-9

#-+*,09

K:9-

-/

09+9-

O*

*9-,

K:9-

+* -9

#-+*,09

K:9-

-/

09+9-

O*

*9-,

JML

Lampiran 9


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Lampiran Lap Akhir Rev Yankesling

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