LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan : Kunjungan Rumah Penderita TB
Di.........................................................................
3. Hasil Kunjungan :
Telah dilakukan kunjungan kepada :
Nama : ................................ Umur : Bln / Th Alamat :.......................................
TTV : - TD :..........mmHg - Suhu : ........C
- Nadi :........x/menit - RR : ........x/ menit
Keluhan :......................................................................................................................................
......................................................................................................................................
4. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

5. Dasar :Surat Tugas Nomor : 800/ /

6. Tujuan Kunjungan : Kunjungan Rumah Penderita DBD
Di.........................................................................
7. Hasil Kunjungan :
Telah dilakukan kunjungan kepada :
Nama : ................................ Umur : Bln / Th Alamat :.......................................
TTV : - TD :..........mmHg - Suhu : ........C
- Nadi :........x/menit - RR : ........x/ menit
Keluhan :......................................................................................................................................
......................................................................................................................................
8. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

9. Dasar :Surat Tugas Nomor : 800/ /

10. Tujuan Kunjungan : Kunjungan Rumah Penderita MALARIA
11.
Di.........................................................................
12. Hasil Kunjungan :
Telah dilakukan kunjungan kepada :
Nama : ................................ Umur : Bln / Th Alamat :.......................................
TTV : - TD :..........mmHg - Suhu : ........C
- Nadi :........x/menit - RR : ........x/ menit
Keluhan :......................................................................................................................................
......................................................................................................................................
13. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Pelayanan Lanjut Usia di posyandu
Di.........................................................................
3. Hasil Kunjungan :
Telah dilakukan posyandu lansiadengan hasil :
1. Jumlah lansia yang ada :
2. Jumlah lansia yang berkunjung :
3. Penyakit terbanyak : 1
2
3

4. Kesimpulan / Saran Perbaikan

Prosentase kunjungan lansia yang datang dibanding jumlah lansia yang ada =................%
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Pendataan Lansia
Di.........................................................................
3. Hasil Kunjungan :
Nama :....................................................................
Umur :....................................................................
Alamat :....................................................................

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan : Pemeriksaan Jentik Berkala (PSN)
Di.........................................................................
3. Hasil Kunjungan : ...........................................
Nama Kepala Keluarga : ...........................................
Umur : ...........................................
Alamat : ...........................................
Keberadaan Jentik : YA TIDAK
Terakhir bak mandi dibersihkan : ...........................................
4. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Kader

( )
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

5. Tujuan Kunjungan :Kontak Serumah Penderita TB
Di.........................................................................
6. Hasil Kunjungan :
Nama Keluarga :.............................................
Tanda tanda TB : YA TIDAK

7. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan :Pendataan Siswa Sekolah
Di.........................................................................
3. Hasil Kunjungan :
Kelas 1 Kelas 4 Jumlah siswa
L :....... P :....... L :....... P :....... L :....... P :.......
Kelas 2 Kelas 5
L :....... P :....... L :....... P :.......
Kelas 3 Kelas 6
L :....... P :....... L :....... P :.......

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2016
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Bias Campak SD Kelas .
Di.........................................................................
3. Hasil Kunjungan :
Jumlah siswa :
L =..........
P =..........
Jumlah Siswa yang mendapat Imunisasi Campak
L =.......
P =.......

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan :Bias Dt Kelas 1, Td Kelas 2 dan Kelas 3
Di.........................................................................
3. Hasil Kunjungan :
Jumlah siswa :
Kelas 1 L =.......... Kelas 2 L=....... Kelas 3 L=.......
P =.......... P=....... P=.......

Jumlah Siswa yang mendapat Imunisasi Dt dan Td

Kelas 1 L =....... Kelas 2 L=....... Kelas 3 L=........
P =....... P=....... P=.......

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2016
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Pengiriman & Pengambilan Spesimen Dahak TB
Di.........................................................................
3. Hasil Kunjungan :
Telah dilakukan Pengiriman & Pengambilan Spesimen Dahak TB pada :
Nama :..............................................
Umur :..............................................
Alamat :..............................................

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan : Survey PHBS TTU Rumah Makan
Di.........................................................................
3. Hasil Kunjungan :
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.
4. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Petugas Promkes Pelapor

SUNARSI ( )
Nip. 19670813 198801 2 003 Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan : Survey PHBS TTU di Institusi Pendidikan
Di.........................................................................
3. Hasil Kunjungan :
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.
4. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Petugas Promkes Pelapor

SUNARSI ( )
Nip. 19670813 198801 2 003 Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan :Penyuluhan / Promosi Etika Batuk
Di.........................................................................
3. Hasil Kunjungan :
Materi Penyuluhan :..................................................................................................
...................................................................................................
Yang hadir
- L =..orang
- P =..orang

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Pelapor

1. Nama .............................. ................

Nip. ..............................
2. Nama .............................. ................
Nip. ..............................
 LAPORAN KEGIATAN

5. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

6. Tujuan Kunjungan :Kunjungan Rumah Keluarga Rawan
Di.........................................................................
7. Hasil Kunjungan :
Nama :....................................................................
Umur :....................................................................
Alamat :....................................................................

8. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /35.07.103.102/2016

2. Tujuan Kunjungan :Kunjungan Rumah Keluarga Rawan
Di.........................................................................
3. Hasil Kunjungan :
Nama :....................................................................
Umur :....................................................................
Alamat :....................................................................

4. Kesimpulan / Saran Perbaikan

..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2016
Kader

1. Nama .............................. ................

Nip. ..............................
2. Nama .............................. ................
Nip. ..............................
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Penyuluhan TB Paru
Di.........................................................................
3. Hasil Kunjungan :
Materi Penyuluhan :..................................................................................................
...................................................................................................
Yang hadir
- L =..orang
- P =..orang

4. Kesimpulan / Saran Perbaikan

5.
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Penyuluhan TB Oleh Kader TB
Di.........................................................................
3. Hasil Kunjungan :
Materi Penyuluhan :..................................................................................................
...................................................................................................
Yang hadir
- L =..orang
- P =..orang

4. Kesimpulan / Saran Perbaikan

5.
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Kader Pelapor

1 . N a m a .............................. ................ 1. Nama.............................. ................

2 . N a m a .............................. ................ 2. Nama.............................. ................

 LAPORAN KEGIATAN

1. Dasar :Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan :Penyuluhan DBD
Di.........................................................................
3. Hasil Kunjungan :
Materi Penyuluhan :..................................................................................................
...................................................................................................
Yang hadir
- L =..orang
- P =..orang

4. Kesimpulan / Saran Perbaikan

5.
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
.........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.
 LAPORAN KEGIATAN

1. Dasar : Surat Tugas Nomor : 800/ /

2. Tujuan Kunjungan : Pemantapan Lansia RESTI
Di.........................................................................
3. Hasil Kunjungan
4. :
Telah dilakukan kunjungan kepada :
Nama : Umur :.. Alamat :..
TTV : TD : Suhu :..
RR : Nadi :..
Diagnosa :
..........................................................................................................................................................
..........................................................................................................................................................
5. Kesimpulan / Saran Perbaikan
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................
..........................................................................................................................................................

, ...........................................2017
Pelapor

( )
Nip.