LEMBAR LAPORAN HARIAN SUPERVISOR

Tgl/Bln/thn :............................................ Provinsi : Kepulauan Riau

Kabupaten : Karimun
Nama/Tanda tangan Supervisor Nama/Tanda Tangan Koordinator

1. Fatrina Susanti

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Dr. H. Ade Kristiawan
NIP. 19740124 200604 1 010
2. Teguh Iman Pramono

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Catatan Briefing

Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan

Enumerator Kel. Tg. Enumerator Kel. Tg. Enumerator Kel. Teluk Enumerator Kel.
Balai Kota Balai Air Lubuk Semut
Anita Turissia Lina Dameria Rambe Christina Anissa Anggria Sari

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Wilayah/Target Wilayah/Target Wilayah/Target Wilayah/Target

Enumerator 1 Enumerator 2 Enumerator 3 Enumerator 4

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Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan

Enumerator Kel. Enumerator Kel. Enumerator Desa Enumerator Desa Parit
Sei.Lakam Timur Sei.Lakam Barat tulang Yuyun Tri Puspita
Aida Madiariany Rusmina Dewi Anggraini

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Wilayah/Target Wilayah/Target Wilayah/Target Wilayah/Target

Enumerator 5 Enumerator 6 Enumerator 7 Enumerator 8

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Nama/Tanda Tangan
Enumerator Desa Selat
Mendaun
Rika Safitri

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Wilayah/Target Enumerator 9

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Check List Kegiatan

No Check items (v)

1. Briefing kuesioner (khusus hari 1)
Check Kelengkapan
2. Pulpen
3. Pensil
4. Penghapus
Kuesioner
5a. Kelengkapan Halaman
5b. Nomor Kuesioner
7 Janji waktu dan tempat debreifing

Catatan Debriefing

Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan

Enumerator 1 Enumerator 2 Enumerator 3 Enumerator 4

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Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan Nama/Tanda Tangan

Enumerator 5 Enumerator 6 Enumerator 7 Enumerator 8

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Nama/Tanda Tangan
Enumerator 9

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Catatan (hal yang memperlancar & kesulitan yang dihadapi & Rencana Solusi)

1. ....................................................................................................................................................
2. .....................................................................................................................................................
3. ....................................................................................................................................................
4. ...................................................................................................................................................
 LEMBAR LAPORAN REKAP HARIAN SUPERVISOR
SURVEY PENILAIAN RISIKO KESEHATAN LINGKUNGAN

Tanggal : Wilayah : Kab. Karimun

Kecamatan : Karimun
Desa/Kelurahan :
Strata :

Nama/Tanda Tangan Supervisor

1. Fatrina Susanti

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2. Teguh Iman Pramono

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Jumlah Kuesioner Terkumpul 1. Kelurahan Tg. Balai Kota : ...........................Kuesioner

2. Kelurahan Tg. Balai :............................Kuesioner
3. Kelurahan Teluk Air :............................Kuesioner
4. Kelurahan Lubuk Semut :............................Kuesioner
5. Kelurahan Sei.Lakam Timur :............................Kuesioner
6. Kelurahan Sei. Lakam Barat :...........................Kuesioner
7. Desa Parit :...........................Kuesioner
8. Desa Tulang :...........................Kuesioner
9. Desa Selat mendaun :...........................Kuesioner