FORMAT MONITORING EVALUASI POS GIZI DI KOTA TANGERANG

NAMA POS GIZI :

ALAMAT POS GIZI :
KEL :
KEC :
WILAYAH PUSKESMAS :
TANGGAL MONITORING DAN EVALUASI :

A. SUMBER DAYA MANUSIA

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1 KADER MINIMAL 5 ORANG

2 PETUGAS KESEHATAN DARI PUSKESMAS

3 STRUKTUR ORGANISASI

B. PERALATAN DAN PERLENGKAPAN

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1 PERALATAN MEMASAK

2 PERALATAN MAKAN DAN MINUM PESERTA

3 TEMPAT CUCI TANGAN

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a. AIR MENGALIR

b. SABUN CUCI TANGAN

 FORMAT MONITORING EVALUASI POS GIZI DI KOTA TANGERA
NAMA POS GIZI :
ALAMAT POS GIZI :
KEL :
KEC :
WILAYAH PUSKESMAS :
TANGGAL MONITORING DAN EVALUASI :

CHECKLIST
NO DESKRIPSI
ADA TIDAK

A. SUMBER DAYA MANUSIA

1 KADER MINIMAL 5 ORANG

2 PETUGAS KESEHATAN DARI PUSKESMAS

3 STRUKTUR ORGANISASI

B. PERALATAN DAN PERLENGKAPAN

1 PERALATAN MEMASAK

2 PERALATAN MAKAN DAN MINUM PESERTA

3 TEMPAT CUCI TANGAN

a. AIR MENGALIR

b. SABUN CUCI TANGAN

4 PERLENGKAPAN ADMINISTRASI

a. KMS

b. PAPAN ABSENSI

c. ABSEN KADER

d. ALAT PERMAINAN EDUKATIF (APE)

e. FORM MONITORING BB PESERTA

f. FORM MONITORING ASUPAN MAKANAN PESERTA

g. MEDIA PENYULUHAN (LEMBAR BALIK/POSTER/DLL)

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5 ALAT ANTROPOMETRI

a. DACIN

b. TIMBANGAN ELEKTRIK

c. ALAT UKUR PANJANG BADAN (UTK PESERTA < 2TH )

MICROTOIS / ALAT UKUR TINGGI BADAN (UNTUK PESERTA >

d. 2TH)

C. PELAKSANAAN KEGIATAN

1 DAFTAR KELOMPOK BELANJA

2 DAFTAR KADER PENDAMPING

3 SIKLUS MENU 10 HARI

a. BERAGAM

b. BERGIZI

c. SEIMBANG

d. AMAN

e. MUDAH DIPRAKTEKKAN IBU PESERTA

6 PEMANTAUAN KESEHATAN OLEH PETUGAS KESEHATAN

7 PEMANTAUAN BERAT BADAN BALITA PESERTA

8 PEMANTAUAN KEBERSIHAN BALITA PESERTA

b. KEBERSIHAN KUKU

c. KEBERSIHAN BADAN DAN PAKAIAN

9 PEMANTAUAN ASUPAN MAKANAN BALITA PESERTA

10 DILAKUKAN EDUKASI DAN PENYULUHAN

BALITA DIAJARKAN BERDOA SEBELUM DAN SESUDAH

a. MAKAN
BALITA DIAJAK BERMAIN SAMBIL MENUNGGU WAKTU
b. MAKAN
BALITA DAN IBU DIAJARKAN PERILAKU HIDUP BERSIH DAN
c. SEHAT (PHBS)
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d. PENYULUHAN KESEHATAN DAN GIZI (JIKA YA SEBUTKAN)

D KERJASAMA

1 KERJASAMA DAN KEKOMPAKAN ANTARA IBU BALITA

KERJASAMA IBU BALITA DENGAN IBU KADER DAN PETUGAS

2 KESEHATAN

PERMASALAHAN DAN KENDALA YANG DIHADAPI :

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Mengetahui,
Ketua Pos Gizi

(…………………………………………………………..)
ZI DI KOTA TANGERANG

URAIAN
URAIAN
 URAIAN

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Petugas Monitoring & Evaluasi

(…………………………………………………………..)
 Kop Puskesmas

LAPORAN HASIL MONITORING DAN EVALUASI KEGIATAN POSYANDU

1 Tanggal : ..............................................................................................................................

2 Nama Posyandu : ..............................................................................................................................

3 Alamat Posyandu : ..............................................................................................................................

Kelurahan : ..............................................................................................................................

Kecamatan : ..............................................................................................................................

Wilayah Puskesmas : ..............................................................................................................................

4 Hasil Monitoring :

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5 Kesimpulan / Saran Perbaikan

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Tangerang,

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