PEMERINTAH PROVINSI BENGKULU

BADAN LAYANAN UMUM DAERAH

RSUD DR. M. YUNUS
Jl. Bhayangkari Bengkulu 38229 Telp. (0736) 52004 – 52006 Fax. (0736) 52007

DAFTAR R + ITEMS :

1. ......................................................................................................................

2. ......................................................................................................................

3. ......................................................................................................................

4. ......................................................................................................................

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

6. ......................................................................................................................

7. ......................................................................................................................

8. ......................................................................................................................

9. ......................................................................................................................

10. ......................................................................................................................

DAFTAR R + ITEMS :
1. ......................................................................................................................

2. ......................................................................................................................

3. ......................................................................................................................

4. ......................................................................................................................

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

6. ......................................................................................................................

7. ......................................................................................................................

8. ......................................................................................................................

9. ......................................................................................................................

10. ......................................................................................................................
 PEMERINTAH PROVINSI BENGKULU
BADAN LAYANAN UMUM DAERAH
RSUD DR. M. YUNUS
Jl. Bhayangkari Bengkulu 38229 Telp. (0736) 52004 – 52006 Fax. (0736) 52007

EVALUASI BULANAN KEMAJUAN ANAK

Nama anak : ………………………………..…………
Nama Terapis Penanggung Jawab : …………….…………….
Nama Terapis Anggota 1. …………………………. 3. ………………………….
2. …………………………. 4. ………………………….
Bulan : ………………………. Tahun : ………………………..

TGL TGL MAINT GENERALISASI KET.

K.M.A AKTIVITAS S = Subyek
MULAI MAST SELESAI S I O L
I = institusi
O = Obyek
L = Lingkungan
 LAPORAN PENILAIAN “HARIAN / PEMELIHARAAN”
TERLAPIS : 1. …………………………. (P. Jawab) nama anak : ………………………………………….
2. …………………………. (Anggota) TRIWULAN : …………..Tgl………………………….
3. …………………………. ( Anggota)
AKTIVITAS TANGGAL / RESPON ANAK (A ATAU P)
K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :

K : ….. Aktivitas :
M :…..
A :….. Instruksi :
 CATATAN PERILAKU AUTIS ANAK
POLI TUMBUH KEMBANG

NAMA ANAK :
PENANGGUNG JAWAB :
BULAN / TAHUN :

TANGGAL
NO PERILAKU 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 KETERANGAN
1 √ = Muncul
2 X = Tidak Muncul
3 - = Off
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
 PEMERINTAH PROVINSI BENGKULU
BADAN LAYANAN UMUM DAERAH
RSUD DR. M. YUNUS
Jl. Bhayangkari Bengkulu 38229 Telp. (0736) 52004 – 52006 Fax. (0736) 52007

PERILAKU AUTIS YANG MASIH TAMPAK :

(MBD DAN TANTRUM)

1. ..................................................................................................................................

2. ..................................................................................................................................

3. ..................................................................................................................................

4. ..................................................................................................................................

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

PENANGANNYA :

1. ..................................................................................................................................

2. ..................................................................................................................................

3. ..................................................................................................................................

4. ..................................................................................................................................

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

PENYEBABPNYA :

1. ..................................................................................................................................

2. ..................................................................................................................................

3. ..................................................................................................................................

4. ..................................................................................................................................

5. ..................................................................................................................................
 PEMERINTAH PROVINSI BENGKULU
BADAN LAYANAN UMUM DAERAH
RSUD DR. M. YUNUS
Jl. Bhayangkari Bengkulu 38229 Telp. (0736) 52004 – 52006 Fax. (0736) 52007

EVALUASI BULANAN
Nama anak :
Terapis penanggung jawab :
Terapis anggota : 1. ………………….. 3. ……………….….
2. ……………….…. 4. ……………….….
Pada tanggal : ……………………..

I. KEPATUHAN : (Lingkari Yang Dipilih)

Duduk mandiri Mau dipromt Menolak diprompt Hiperaktif Tantrum

II. KOTAK MATA :

III. PERILAKU AUTIS YANG MASIH TAMPAK
1. .....................................................................................................................................................................
Penyebabnya (= R – item) : ........................................................................................................................
Penanganannya : ..........................................................................................................................................
2. .....................................................................................................................................................................
Penyebabnya (= R – item) : .........................................................................................................................
Penanganannya : ..........................................................................................................................................
3. .....................................................................................................................................................................
Penyebabnya (= R – item) : .........................................................................................................................
Penanganannya : ..........................................................................................................................................
4. .....................................................................................................................................................................
Penyebabnya (= R – item) : .........................................................................................................................
Penanganannya : ..........................................................................................................................................
5. .....................................................................................................................................................................
Penyebabnya (= R – item) : .........................................................................................................................
Penanganannya : ..........................................................................................................................................
.....................................................................................................................................................................
IV. MASALAH LAIN YANG DIJUMPAI DAN PENANGANANYA
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
...........................................................................................................................................................................
 PEMERINTAH PROVINSI BENGKULU
BADAN LAYANAN UMUM DAERAH
RSUD DR. M. YUNUS
Jl. Bhayangkari Bengkulu 38229 Telp. (0736) 52004 – 52006 Fax. (0736) 52007

Nama anak :
Nama terapis PJ : ………………..

RENCANA (GENERALISASI HASIL KEGIATAN

Rencanakan generalisasi dari aktivitas yang Pakailah istilah yang dipakai di sekolah spt A
sesudah di mastered anak di sekolah dan di dan P. jangan mempergunakan istilah awam
sesuaikan dengan lokasi yang dikunjungi spt : hampir bisa, hampir konsisten, agak
bisa, dsb

1. KEPATUHAN

2. KONTAKMATA

3. MENIRUKAN

4. BAHASA RESEPTIF

5. BAHASA EXPRESIF

6. BAHASA ABSTRAK

7. SOSIALISASI

8. AKADEMIK

9. BANTU DIRI
 LEMBAR PENCATATAN ANALISA
Skor Prompt :
PA = full physical assistance (prompt penuh)
M = modeling (dicontohkan)
V = verbal directions (prompt verbal)
I = independent (mandiri)

NAMA :………………………………. INTRUKSI AWAL :………………………………………..….

INSTRUKTUR :………………………………. KRITERIA KEBERHASILAN :………………………………
LINGKUNGAN :………………………………. ………………………………………………………………….
BIDANG PENDIDIKAN :………………………………. ………………………………………………………………….
SOS :………………………………. ………………………………………………………………….
FOKUS KETERAMPILAN :………………………………. ………………………………………………………………….

Tanggal Tanggal
komentar
Langkah-Langkah Pre-tes modifikasi Hasil Kerja
 KOLEKSI DATA HARIAN untuk DRILLING
K M A Materi : K M A Materi : K M A Materi :
Instruksi : Instruksi : Instruksi :
Hari:…………... Tgl :…………….Jam :……….. Hari :………………… Tgl :…………….Jam :……….. Hari :………………… Tgl :…………….Jam :………..
Setting :……………………... Terapis :…………….. Setting :……………………... Terapis :…………….. Setting :……………………... Terapis :……………..

No Aktivitas B/S/P .../…. P No Aktivitas B/S/P .../…. P No Aktifitas B/S/P .../…. P

1. 1. 1.

2. 2. 2.

3. 3. 3.

4. 4. 4.

5. 5. 5.

6. 6. 6.

7. 7. 7.

8. 8. 8.

9. 9. 9.

10. 10. 10.

Total : Total : Total :

 EVALUASI PROSES TERAPI
Nama Anak :………………… Materi (Aktivitas) : Supervisor :
Terapis :………………… Periode tanggal :…….s/d…….
Tanggal :………………… Jml yang diajarkan (a) :…………. (Paraf)
Jam :………s/d……… Jml yang mastered (m) :………….
Triwulan ke- :………………… Prosentase (m/a) :………….% (Nama) …………………...

ANAK
kepatuhan Duduk atas instruksi  Patuh – tidak patuh Duduk lama :  Tenang – gelisah
Kontak mata  1 dtk – 3 dtk – 5 dtk  Konsisten – tidak konsisten
Perilaku autistik yang tampak :
 MBD : …………………………………………………………………………………….
 Tantrum : …………………………………………………………………………………….
Respon anak terhadap instruksi terapis :
 Bergairah – tanggap – kurang tanggap – cuek – MBD (Sebutkan apa) :……………………….
Respon verbal  Sudah ada – belum ada  Volume suara : keras – sedang – lemah
 Artikulasi suara : sempurna – baik – sedang - jelek
TERAPIS
Instruksi Terapis :
 Singkat – jelas – tegas – tuntas – sama
 Tambahan instruksi : ada – tidak ada
 Rayuan : ada – tidak ada
Prompt yang diberikan :
 Tepat – terlambat – tidak ada
 Lembut tegas – pakai kekerasan
Imbalan yang diberikan :
 Cara pemberian : tepat waktu – terlambat – tidak diberi
 Materi : makan – minum – mainan – benda lain :…………………………………...(Sebutkan)
 Verbal : pujian – nyanyian
 Ekspresi terapis : meriah – datar – kecewa – marah
 Taktil : ciuman – pelikan – belaian – gelitikan – tepukan
 Aksi lain : Toss – Yes – PDIP – lainnya :……………….
 Respon anak thd imbalan :sumringah (ceria) – datar (cuek) – cemberut – menangis – tantrum
kekerasan  Melotot – berteriak – membentuk – mengancam – mendorong – memukul – lainnya :……….
ketegasan  Baik – sedang – kurang - jelek

SARAN-SARAN :
1)

2)

3)

4)

5)

6)

7)