CHECKLIST MONEV BANTUAN OPERASIONAL (BOK) PUSKESMAS

DINAS KESEHATAN KABUPATEN REMBANG

TAHUN ANGGARAN 2019

I. DATA UMUM
1. Nama Puskesmas : ..............................................................................
2. Jumlah Pegawai : ..............................................................................
a. PNS : ..............................................................................
b. Non PNS : ..............................................................................
3. Jumlah Desa/ Kelurahan : ..............................................................................
4. Jumlah Penduduk : ..............................................................................

II. PERENCANAAN DAN EVALUASI

1. POA BOK : Ada / Tidak
2. DPA BOK :
- Induk : Ada / Tidak
- Pergeseran/ Perubahan : Ada / Tidak
3. Lokmin Bulanan 2019 : Target ............... Kali
Bulan .....................................................................
.
Notulen : Ada/ Tidak

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
3. Lokmin Tribulanan 2019 : Target ............... Kali
Bulan .....................................................................
.
Notulen : Ada/ Tidak

.............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
4. Pertemuan Linsek 2019 : Target ............... Kali
Bulan .....................................................................
.
Notulen : Ada/ Tidak

Catatan : ...............................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
5. Pertemuan Linprog 2019 : Target ............... Kali
Bulan .....................................................................
.
Notulen : Ada/ Tidak

..............................................................................................................................................
..............................................................................................................................................
..............................................................................................................................................
6. Iuran BPJS Kesehatan : Ya / Tidak

7. Iuran BPJS Ketenagakerjaan : Ya / Tidak

8. Laporan SPM :
Jumlah Indikator Triwulan I Triwulan II Triwulan III Triwulan IV
..... indikator
..... indikator

9. Total Penyerapan anggaran : Rp. ...................................... s/d bulan September 2019

10. Realisasi per Upaya Kesehatan sd bulan : September 2019
 Realisasi
No Upaya Kesehatan Pagu (Rp) Keuangan
(Rp)
1. Program Indonesia Sehat Melalui
Pendekatan Keluarga
2. Upaya Kesehatan Masyarakat Esensial
(Pelayanan promosi kesehatan; Pelayanan
kesehatan lingkungan; Pelayanan
kesehatan ibu, anak, dan keluarga
berencana; Pelayanan gizi; dan Pelayanan
pencegahan dan pengendalian penyakit)
3. Upaya Kesehatan Masyarakat
Pengembangan dan Upaya Kesehatan
lainnya
4. Pelaksanaan Fungsi Manajemen (P1, P2,
dan P3)
5. Sanitasi Total Berbasis Masyarakat
6. Nusantara Sehat
7. Dukungan Manajemen
JUMLAH

III. KEUANGAN

NO LIST ADA TIDAK KETERANGAN

1. BKU PER BULAN

2. SPJ FUNGSIONAL PER BULAN

REKAP PERMINTAAN BAYAR
3.
TUNAI DAN NON TUNAI

4. SPJ FISIK BOK PER BULAN

5. BUKU BANTU ( PAJAK, DLL )

TANDA TANGAN SPJ SUDAH

6.
LENGKAP (TERUTAMA C5)

7. DPA BOK PUSKESMAS

SPJ MASUK VERIFIKATOR

8. DINKES SAMPAI DENGAN
BULAN SEPTEMBER 2019

KENDALA YANG DIHADAPI DALAM PENYUSUNAN SPJ BOK

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

REALISASI KEUANGAN BOK PUSKESMAS

Pembayaran Jenis SPJ
No Bulan Jumlah
Tunai Non Tunai LS GU TU
1. Januari
2. Februari
 3. Maret
4. April
5. Mei
6. Juni
7. Juli
8. Agustus
9. September
10. Oktober
11. November
12. Desember
JUMLAH

CATATAN
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................
.......................................................................................................................................................

Petugas Monev

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