Format1

LAPORAN KEJADIAN BENCANA ALAM DI WILAYAH KERJA PUSKESMAS

A. Jenis Kejadian
.........................................................................................................................................
B. Waktu Kejadian
.........................................................................................................................................
C. Lokasi Kejadian
.........................................................................................................................................
D. Penyebab Kejadian/Kronologis Kejadian
................................................................................................................................................................
................................................................................................................................................................
................................................................................................................................................................
............................................................................................
E. Dampak Kejadian :
a. Jumlah Daerah yang masih terdampak : ......................................
No Nama Desa/Wilayah Jumlah KK Terdampak Keterangan
1 ...........................................
2 ...........................................
3 ...........................................
4 ...........................................
5 ...........................................
6 ...........................................

b. Jumlah Total KK terdampak : ......................................

c. Jumlah orang sakit : ......................................
d. Jumlah dan jenis kasus penyakit : ......................................

No Nama Umur Jenis Penyakit Keterangan

1
2
3
4
5
6

e. Dampak pada fasilitas umum dan perumahan warga :

.........................................................................................................................................................
.........................................................................................................................................................
F. Upaya yang dilakukan oleh Puskesmas :
a. Membentuk Posko Kesehatan
b. Penanganan/Upaya yang dilakukan
...........................................................................................................................................................
...........................................................................................................................................................
G. Sumber Data
................................................................................................................................................................
Format2

LAPORAN HARIAN SITUASI BENCANA ALAM DI WILAYAH KERJA PUSKESMAS

A. Jenis Kejadian
.........................................................................................................................................
B. Waktu/Tanggal dan Jam Pelaporan
.........................................................................................................................................
C. Dampak Kejadian
.........................................................................................................................................
a. Jumlah Daerah yang masih terdampak : ......................................
No Nama Desa/Wilayah Jumlah KK Terdampak Keterangan
1 ...........................................
2 ...........................................
3 ...........................................
4 ...........................................
5 ...........................................
6 ...........................................

b. Jumlah Total KK terdampak : ......................................

c. Jumlah orang sakit : ......................................
d. Jumlah dan jenis kasus penyakit : ......................................

No Nama Umur Jenis Penyakit Keterangan

1
2
3
4
5
6

e. Dampak pada fasilitas umum dan perumahan warga :

.........................................................................................................................................................
.........................................................................................................................................................
D. Upaya yang dilakukan oleh Puskesmas :
c. Membentuk Posko Kesehatan
d. Penanganan/Upaya yang dilakukan
...........................................................................................................................................................
...........................................................................................................................................................
E. Kondisi saat ini
................................................................................................................................................................
F. Sumber Data
................................................................................................................................................................

(catatan : Data laporan dapat dikirim ke email yankesrujukanstg@gmail.com)