INSTRUMEN MONITORING DAN EVALUASI PROGRAM PKPR

(PELAYANAN KESEHATAN PEDULI REMAJA)

PUSKESMAS : .............................................. KECAMATAN : ..............................................

KABUPATEN : GARUT TANGGAL MONEV : ..............................................

A.SDM KESEHATAN Y T
1. Apakah ada Petugas pengelola program yang bertanggung jawab?
Kalo Ya, apakah mempunyai surat tugas dari Puskesmas?
Kalo Ya, apakah terlatih?
2. Apakah mempunyai Buku Pedoman Pelaksanaan PKPR?
3. Apakah tersedia Sarana ruangan tempat kegiatan PKPR di Puskesmas?
Kalo Ya, Apakah tersedia Kit/Media Konseling PKPR?
Kalo Ya, Apakah ada jadwal piket pelayanan?
4. Apakah kegiatan PKPR dilaksanakan di Sekolah?
Kalo Ya, berapa Sekolah? ......................................................
Kalo Ya, Sekolah mana? ..................................................................................................
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Kalo Tidak dilaksanakan di Sekolah, Alasan? ...............................................................................
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5. Apakah ada Format untuk kegiatan PKPR?
6. Apakah ada Format untuk Instrumen Kepuasan kegiatan PKPR di puskesmas?
7. Apakah ada Register kegiatan PKPR?
Kalo Ya, apakah digunakan?
Kalo tidak digunakan, Alasan? .......................................................................................................
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8. Apakah ada Format Pelaporan kegiatan PKPR?
9. Apakah ada SOP kegiatan PKPR?
10. Apakah ada Standar Pelayanan (SP) kegiatan PKPR?
11. Apakah tersedia data sasaran remaja per desa/kelurahan?
Kalo Tidak, Alasan? .......................................................................................................................
12. Apakah tersedia anggaran untuk kegiatan PKPR?
Kalo Ya, Jenis sumber anggaran? ...................................................................................................
Kalo Tidak, Alasan? .......................................................................................................................
13. Apakah tersedia Dokumen Perencanaan kegiatan PKPR?
Kalo Tidak, Alasan? .......................................................................................................................
B. PROSES
1. Apakah Sosialisasi program PKPR secara Lintas Program sudah dilaksanakan?
Kalo Tidak, Alasan? .......................................................................................................................

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2. Apakah Sosialisasi program PKPR secara Lintas Sektor sudah dilaksanakan?
Kalo Tidak, Alasan? .......................................................................................................................
3. Apakah Kajian kegiatan PKPR sudah dilaksanakan?
Kalo Tidak, Alasan? .......................................................................................................................
C. OUTPUT
1. Apakah Laporan Bulanan PKPR tahun ini untuk ke Dinas dibuat?
Kalo Tidak, Alasan? .......................................................................................................................
2. Apakah Laporan PKPR rekap Triwulan tahun ini dibuat?
Kalo Tidak, Alasan? .......................................................................................................................
3. Apakah Laporan PKPR rekap Semester tahun ini dibuat?
Kalo Tidak, Alasan? .......................................................................................................................
4. Apakah Laporan PKPR rekap Tahunan tahun ini s.d. Bulan terahir dibuat?
Kalo Tidak, Alasan? .......................................................................................................................
5. Cakupan remaja yang mendapatkan pelayanan kesehatan remaja di Puskesmas ..................................... %
6. Cakupan jumlah Kader Kesehatan Remaja setingkat SMP ................................... %
7. Cakupan jumlah Kader Kesehatan Remaja setingkat SMA ................................... %

USUL ATAU SARAN KE DINAS KESEHATAN UNTUK KEGIATAN PROGRAM PKPR DI PUSKESMAS/SEKOLAH:
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PEJABAT YANG DI KUNJUNGI PETUGAS BINTEK/ MONEV

NAMA : .............................................................. NAMA : ……………………………..

NIP : .............................................................. NIP : ………………………………

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