Form Rumah Sakit Dan Puskesmas

7/26/2019 Form Rumah Sakit Dan Puskesmas

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@. +rin8n int0i " . Amn (e 4r4nne4tin#

=

. Ter0in%n8 *

1 2 3 4 5 61. S0rn ir 0im! 1 . Ter0in%n8 *

. Tertt5

. A0irn ir 0n4r

II RUANG BANGUNAN(Ju!"# B$%$& 1' )

1 Rn8 5er'tn 2 . R%i 0 0nti%en8n tem5t ti%r :- De' : *" m2/tt

- An6 /&i : 2 m2/tt

2

. R%i tem5t ti%r%en8n 6mr mn%i 1-1 tt/6mr mn%i %n ti0et

1

4 An86 6mn 1


3/18

0n8it 2"> 3"3 m %ri 0nti

e. Keiin8n =?%BA

1

*. Rn8 teri0ii 1" . Pint m6

ter5i! %en8n 5int 6e0r

. Tere%i rn86!

3

4. Din%in8 tert%ri 5re0in / 6ermi6 etin88i 1"m %ri 0nti

2

. Rn8 r%i08i " . Din%in8 %n%n 5int %i05ii tim! !itm

3

. K4 en%e0

men88n6n 64 tim! !itm

3

4. Tin88i 0n8it 0n8it

2

%. Hn8n%en8n rn8 8e05 !r %en8n06et

2

=. Rn8 5en%in8in 1 . S! 1 C /% E C

. Be ti6 / 6e46 *

4. Di0en865i r6 nt6 men&m5n

m6nn %en8n tin88i 2-2

1


4/18

e4r 6teri 08i memen!i&rt

2. Tem5t 5en&im5nnm6nn %n m6nn

%i

3 . M6nn &n8m%! mem6 %iim5n 5%

! ="C t *C

3

. M6nn &n8 6n%ii6n = m %i im5n 5%! -C /% 1C

3

4. Beri! 1

%. Ter0in%n8 %ri %e 1

e. Be %ri8n88n ern88 %n ti6

1

7. B!n m6nn %n

m6nn %i ter5i!

1

3. Pen&in m6nn 2 . Men88n6n 6eret%rn8 tertt5

. Ti%6 men&i6nm6nn %i &n8 %!men8in5

*

4. L0 0int m6nn%i men88n6n 0r 6!

1

*. Tem5t 5en80!n

0!n m6nn (%5r#

2 . Lnti %5r

ee0m %n e%! 6e8itn%ieri!6n %en8n nti e5ti4

. Di0en865i %en8nn865 %n 4ern8 5

2

4. Pen4!&n 2 2


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VIII STERILISASI ALAT DANPERLENGKAPAN MEDIS

1 . Men88n6n 5er0tn teri0ii5 (t409e# / 8 %en8n !e6itr 132C t. Per0tnrii 8e0mn8 mi6r

(mi6r'9e# t %en8n 4r 0in&n8 memen!i &rt.

*

. A0t %n 5er0en865n me%i &n8%! %iteri06n t %i im5n5% tem5t 6! &n8 teri050

3

4. A0t %n 5er0en865n 65nme%i &n8 %! %iteri06n t%i%ein7e6i ter0ei! %!0 %i

eri!6n %ri %er!. +rin8nt! %n i !n 0in

2

%. Per0tn teri0ii %i60iri min.e60i/t!n

1

I PERLINDUNGAN RADIASI 2 . Int0i %n 8%n8 5er0tnr%ii %i tem5t6n 5% 06i&n8 ! %ri tem5t &n8 r'n6e6rn" tem5t er6m50rn8 n&6

. Te0 !n 5er0in%n8n 5%min8 min8 rn8ner%r6n eni ener8i r%ii"6ti7it %imeni mer r%iiert i7t !n 5er0in%n8 ei


7/18

(.#

NIP :

K,T,RANAN :

$$$$$ # Cret &n8 ti%6 5er0


8/18


9/18

Den8n 4r 6re minim0 nt6 min8-min8 9rie0 5& %0! e5erti teret 5%te0 eri6t :

TYPEKLAS

RS

SKORE MINIMAL DARI MASING:MASING VARIABEL UPAYA(D"!" ;)

I II III IV V VI VII VIII I I

A $# > > @ ? ? ? > 1 = =

B $# > > @ ? ? ? > 1 = =

C $# > > @ ? ? 2 > = =

D $# > > ? ? ? 2 > = 2


10/18


11/18

1. P8r 1 . A%n& 58r 0in86n8n &n8memti m&r6t %en8nn8nn P6em

. P8r 6t %n eri!

4. Ti%6 % 8in 58r &n8r6.

%. A%n& 5int m6 / 6e0r

3

3

2

2

2. H0mn (tmn" 0n %n tem5t 5r6er

1 . A%n& tmn. A%n& tem5t

5r6ir4. H0mn" tmn %n

tem5t 5r6ir tm56 eri!%. Tmn %i5e0i!r%n tertt r5i

e. Tere%i tem5tm5! ementr

212

32

3. Ter 2 . Ter %n 0ntiti%6 ret6

. Beri!4. Ke%5 ir %. M%! %ieri!6n

3322

*. Din%in8 0r n8nn * . Ti%6 ret6 P 6 t

32


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II. BANGUNAN DALAM (Bt 1#

KOMPONEN YANG DINILAI

VARIABEL UPAYA KESEHATAN LINGKUNGAN KETERANGAN

N2!"2

R.

4,

.Pu64

R.

R","&

R.

T"&"U6"#"

R.

P-1"

>&"3"-

R.T

u-0u

P

$!.KB

P$

!.G202

P$!.Uu

P$!.KIA

P$

!.G2?2

A,$&24

L"%$3"&$32u

Gu1"-0

D",u3

T$2!&

R"@"&I-",

Ju!"#

1 2 3 4 5 6 8 9 1' 11 12 13 14 15 16 18 19 1 2'

1. DINDING. Ti%6 ret6. Pern6n rt4. Ct er'rn tern8

(5ti!/6rem#%. Beri! %ri n% / 4retn

e. Tert %ri 5re0in (min 1"#

Km5nen %in%in8tert %ri 5re6! 0rtrim

31

3

1

2+m0!

Bt 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

S4re 2

2. PINTU JENDELA KAA 7 VENTILASI. D0m 6e%n i6. Pint %5t men4e8!

m6n& ern88 / 6e464. K4 en%e0 eri! %n ti%6

5e4!%. )enti0i tere%i er7n8i %n

menmin r n&mn

32

32

+m0!

Bt 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3S4re 2


13/18

1 2 3 4 5 6 8 9 1' 11 12 13 14 15 16 18 19 1 2'

3. ATAP DAN LANIT-LANIT. Ln8t-0n8it minim0 2" M %ri

0nti. Ln8it-0n8it rt %n ti%6

ret64. At5 ti%6 4r

%. M%! %ieri!6ne. Beri!

2

1

32

2

+m0!

Bt 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

S6re 3

*. LANTAI. Rt %n ti%6 ret6. Beri!4. Ke%5 ir %. M%! %ieri!6n

23

3

2

+m0!

Bt

S6re .*

. TATA RUANAN DAN P,N,RANAN. Penern8n 465 nt6

mem4 5% %r 50in8 8e05. Pentn rn8n r5i

+m0!

Bt * * * * * * * * * * * * * * * * *

S4re

N!" C$ (1 2 3 4 5)

Keterangan :Nilai = Jumlah dikalikan bobot

1 2 3 4 5 6

III SARANA +ASILITASSANITASI


14/18

(Bt *3#1. Pen&e%in ir 1 . Tere%i ir eri!

%0m m0! &n8 465 (1" 1"? M3#

. Memen!i &rt60it ir eri!

4. Ditrii irmen88n6n 5er5i5n

%. Tere%in&n 6

44i tn8n 5% nit 5e0&nnPemeri6n KIA-KB" Rn8 i8i"Lrtrim

3

3

1

3

2. +mn / 6mr mn%i @ . Tere%in& 6mrmn%i %n C nt6 6r&'n (1: 1#

. Kmr mn%i %n66 6r&'n 5ri %n 'nitter5i!

4. Tere%in& 6mrmn%i %n 66 5en8nn8

%. Beri!" ti%6 e. S0rn

5emn8n ir 0im! %in86e Se5ti4 Tn6

7. Ri 6mr mn%i/66 %en8n tem5t ti%r (1:#(K! P6em Per'tn#

2

1

1

22

2

3. SPAL ? . A%n& 0rnSPAL

. Ber7n8i4. Air 6tr %ri 6mr

mn%i %n rn8n 5e0&nn%i0ir6n 6e SPAL

%. S0rn ir 0im!tertt5

e. Dn 6e%5 ir

222

22

*. Sm5! 1 . A%n& tem5tm5! %i ti5-ti5 rn85e0&nn

. Tem5t m5!6e%5 ir

2

23


15/18

4. A%n& 5emi!nm5! In7e6i %n nnIn7e6i

%. Pen8n8nm5! eti5 !ri (1 60i 2* m#

e. Penn8nnm5! in7e6i men88n6n5n tin88i

2

1

. t7e0 = . Tere%in& 't7e0

. Ber7n8i %en8ni6

4. Tere%i 5%5e0&nn KIA-KB Lrtrim"P0i i8i / R. Per'tn

%. Tere%i Gt ntie5ti6

e. A% 05 5en8erin8.

2

22

22

IV MANAJEMEN DALAMKEBERSIHAN DAN

KETERANGAN (B$%$& < 22)1. Pen80!n PPBT 1 . %n& r8nii P6 PPBT 2

. % 5e%mn PPBT4. % 5enrn rin t8 56

PPBT

21

%. % !i0 5eni0in PPBT eti50n

1

e. % ri5 05rn PPBT 6e Dti IIeti5 3 0n

1

7. % 5eminn 2

8. Tere%in& 0t 0t 6eeri!n6etertin P6em

1

2. Penm5i0n T8 * . Penm5i0n r5i %n eri! 2

. P6in er8m 34. Mem6i trit 0en865 3

%. Beri65 rm! 23. Dii50in 5et8 * . A%& 6 tm 1


16/18

. %n& %7tr !%ir 58i %n re 24. % rin t8 eti5 5et8 *

%. !%ir %n 50n8 te5t '6t 3

*. Ketertin * . A0r nit 5e0&nn tertr 2. % 55n nm P6em 2

4. % 55n nm rn8 %i intirn8

2

%. % 5et8 5i6et *

V RUANG TAMBAHAN * . %n& rn8 r5t teren%iri *

. %n& m!0 *4. % rn8 / tem5t nt6 6e8itn

0! r82

Men8et!i : Pet8 Pen8' / Pemeri6

K. Din. Ke. Pr5. Dti 1/ 1. Nm : ...

K/K%& Dti 11 $$$$

(.#

.. NIP :

2. Nm : ...

(.#

NIP :

3. Nm : ...

(.#

NIP :

K,T,RANAN :

$$$$$ # Cret &n8 ti%6 5er0

PETUNJUK PENGISIAN +ORMULIR PENILAIAN DAN PELAPORAN

PUSKESMAS BERSIH DAN TERTIB


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A. PENILAIAN PPBT

A5e6 5eni0in ter%iri t :

. Peni0in 6n%ii 7ii6 56em me0i5ti : 8in 0r. B8in %0m 56em %n rn 7i0it niti %n rn8 tm!n

%. Peni0in 5e6 Mn8emen 6eeri!n %n 6etertin 56em me0i5ti : 5en80!n PPBT" 5enm5i0n 5et8. Dii50in 5et8 %n 6eterti

Srn 5e06nn 5eni0in 56em eri! terti %i 8n6n intrmen 5eni0in %n 6etern8n e8i eri6t :

. Intrmen PPBT %i 56i nt6 5eni0in 6e5% rn 56em" 56em %en8n 5er'tn (DTP# %n 56em 5emnt.

- Unt6 56em DTP : Ter%iri nmr %en8n 3@* 5m5nen 5eni0in

- Unt6 56em : Ter%iri nmr %en8n 3>2 6m5nen 5eni0in

- Unt6 56em 5emnt : Km5nen &n8 %ini0i 5% 9rie0 5& &n8 ti%6 %i066n 5eni0in %0m 5e06nn PPBT ini %ie6n 6ren

5e0&nn &n8 tert" m6 nt6 6m5nen &n8 %ini0i ti%6 term6 %0m 5eni0in J e!in88 6re m6im0 %i 6rn8i %en8n 6re m6im0 6m

ni0i.

%. K$,$-- /"-0 - !"

A5i0 6en&tn &n8 % ti%6 memen!i 5er&rtn e8imn ter4ntm 5% 6m5nen &n8 %ini0i" m6 ni0in& (n0#" e0i6n& 5i0 meme

m6 ni0in& %0! eer ni0i &n8 ter4ntm.

V""%! U,"/"

C. )rie0 eti5 8in t eti5 6e8itn %ri 9rie0 5& memi0i6i ni0i ntr (n0# m5i %en8n 1.

. S$

S6re %0! 5er60in ntr t %en8n ni0i &n8 ter4ntm

. Tt0 e0r! !i0 5eni0in 6em%in %im0!6n

-Ni0i m6im0 nt6 56em DTP : 3@*

- Ni0i m6im0 nt6 56em : 3>2

- Ni0i m6im0 nt6 56em Pemnt : 5eni0in m %en8n 5eni0in 56em %en8n eer5 !0 %iei6n %en8n 6n%ii 90me 6e8i

5emnt. Unt6 6m5nen &n8 %ini0i 5% 9rie0 5& &n8 ti%6 %i066n 5eni0i 5% 56em 5emnt 6ren 6etertn 6emm5n nt


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6e8itn 5e0&nn" m6 nt6 6m5nen &n8 %ini0i ti%6 term6 %0m 5eni0in J e!in88 6re m6im0 %i6rn8i %en8n 6re m6im0 %i6rn

m6im0 &n8 %ini0i

>. Penentn 6riteri 0&6 e!t

- P6em DTP : >

: P6em : =

: P6em 5emnt : =

B. P!",$"- PPBT

1. Tin86t 56em

Pe05rn %ri 56em 6e Dti II %i06n6n eti5 = 0n &it 5% 0n +nri %n 0n +ni.

2. Tin86 Dti II

Pe05rn %ri Dti II Pr5ini %i06n6n eti5 = 0n &it 5% 0n

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