REKAPITULASI HASIL PEMERIKSAAN JENTIK AEDES AEGYPTI DALAM RANGKA PSN DBD

TAHUN 20.........
PUSKESMAS : ……………………………… Form 4
KECAMATAN : ………………………………
JUMLAH DESA/KEL : ………………………………
JUMLAH RUMAH : ………………………………
BULAN : ………………………………

CONTAINER
Pecahan JUMLAH
JUMLAH RW JUMLAH RT JUMLAH JUMLAH Bak Kamar
Tempayan Botol/Air Barang Bekas Kulkas/Dispenser Tandon Air Vas Bunga Pot Bunga Lain-lain CONTAINER CONTAINE
NO. DESA/KEL RUMAH RUMAH Mandi
Kemasan R INDEX
DIPERIKSA POSITIP
SELURUH AKTIF SELURUH AKTIF Jml + Jml + Jml + Jml + Jml + Jml + Jml + Jml + Jml + Jml +
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

10

JUMLAH

ANGKA BEBAS JENTIK ( ABJ ) : = Jumlah rumah diperiksa - Jumlah rumah positip jentik X 100% …………………………………, …………………………………... 20........
Jumlah rumah diperiksa
Ketua TP PKK Kelurahan/Desa

= ………………..

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 CHEKLIST PEMANTAUAN PSN DI DESA/KELURAHAN ENDEMIS DBD

Tanggal : ............................................
Desa/Kel. : ............................................
Kecamatan : ............................................

A. DATA WILAYAH
1. Jumlah RT yang ada : ............................................................
2. Jumlah RT melaksanakan PSN : ............................................................

B. PELAKSANA DAN PEMANTAU

1. Siapa saja yang melaksanakan PSN ? : ............................................................
2. Adakah Jadwal Pelaksanaa ? : ............................................................
3. Adakah Tim Pemantau Tingkat Desa ? : ............................................................
4. Apakah kegiatan dipantau dari Kecamatan ? : ............................................................

C. HASIL KEGIATAN
1. PSN dimulai jam berapa ? : ............................................................
2. Siapa saja yang melaksanakan PSN ? : ............................................................
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3. Pemeriksaan jentik dilakukan dimana saja ? : ............................................................
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4. RT mana saja yang melaksanakan PSN ? : ............................................................
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5. Berapa ABJ-nya ? : .............. ( lihat rekapitulasi laporan )

D. MASALAH/KENDALA
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E. SARAN/MASUKAN
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............................,.........................20
Mengetahui Tim Pemantau
Lurah/Kepala Desa ......................
1. .........................................................

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

............................................. 3. .........................................................
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i laporan )

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 CHEKLIST MONEV PSN DI PUSKESMAS

Tanggal : ............................................
Puskesmas : ............................................

A. DATA WILAYAH
1. Jumlah Desa yang ada : ............................................................
2. Jumlah Desa rutin melaksanakan PSN : ............................................................

B. PELAKSANA DAN PEMANTAU

1. Siapa saja yang melaksanakan PSN ? : ............................................................
2. Adakah Jadwal Pelaksanaan ? : ............................................................
3. Adakah Tim Pemantau Tingkat Desa ? : ............................................................
4. Apakah kegiatan dipantau dari Kecamatan : ............................................................
dan Puskesmas ?

C. MASALAH/KENDALA
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E. SARAN/MASUKAN
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............................,.........................2016
Mengetahui
Kepala Puskesmas ......................

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..........2016

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 TANDA TERIMA KAOS

Telah terima kaos sejumlah 50 buah dari IDI Cabang Banyumas

dalam rangka Pencanangan PSN Secara Serentak di Kabupaten Banyumas.

Purwokerto, 6 Maret 2014

Yang menyerahkan Yang menerima,

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

TANDA TERIMA KAOS

Telah terima kaos sejumlah 50 buah dari IDI Cabang Banyumas

dalam rangka Pencanangan PSN Secara Serentak di Kabupaten Banyumas.

Purwokerto, 6 Maret 2014

Yang menyerahkan Yang menerima,

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