FORM : 01/PJ.

UKM-01

PEMERINTAH KABUPATEN BANGLI

DINAS KESEHATAN
UPT PUSKESMAS KINTAMANI 1
Jln Raya Kintamani - Bangli Kode Pos 80652
Telepon (0366) 51040

LEMBAR MONITORING DAN PEMBINAAN

PROGRAM UPAYA KESEHATAN MASYARAKAT ESENSIAL
UPT PUSKESMAS KINTAMANI 1

Program UKM Esensial :

Petugas Pemegang Program :
Periode Pembinaan : ..../..../ 2016
Kegiatan Progam :

1. Analisis Kesesuaian :
Kriteria Perencanaan Realisasi Keseuaian
Sasaran (warga) ⎕ ya ⎕ tidak
Tempat ⎕ ya ⎕ tidak
Waktu ⎕ ya ⎕ tidak
Metode ⎕ ya ⎕ tidak
Tata Nilai 5T ⎕ ya ⎕ tidak
SOP ⎕ ya ⎕ tidak
Capaian ⎕ ya ⎕ tidak

2. Analisis Situasi & Kendala yang Ditemui di Lapangan :

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3. Rincian rencana tindak lanjut yang disepakati :
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Simpulan :
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Supervisi :
Penanggung Jawab UKM Esensial Penyusun

Gede Krisna Udiana, SKM ..................................................

NIP. 19871212 201503 1 005 NIP. ........................................