Lampiran 1

FORMAT PENGKAJIAN KELUARGA

A. Data umum

1. Nama KK :……………………………………
2. Umur KK : ……………………………………
3. Alamat : ……………………………………
4. No. Telephon : ……………………………………
5. Pekerjaan : ……………………………………
6. Pendidikan: ……………………………………
7. Susunan Anggota Keluarga :

Sex Tgl Lahir Gol

No Nama Pendidikan Pekerjaan Hubungan
(L/P) (umur) Darah

Genogram ( dibuat 3 generasi )

8. Tipe Keluarga
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9. Latar belakang kebudayaan (etnik)

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10. Identifikasi religius

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11. Status kelas sosial
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12. Mobilitas kelas sosial
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B. Riwayat Keluarga dan Tahap Perkembangan

13. Tahap perkembangan keluarga saat ini

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14. Tahap perkembangan keluarga yang belum terpenuhi

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15. Riwayat keluarga inti

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16. Riwayat keluarga asal

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C. Data Lingkungan

17. Karakteristik rumah

Denah rumah

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18. Karakteristik lingkungan tempat tinggal dan masyarakat

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19. Mobilitas geografis keluarga

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20. Hubungan sosial keluarga dengan masyarakat

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