KUESIONER SURVEY PERILAKU HIDUP BERSIH DAN SEHAT

(PHBS) DI SEKOLAH

NAMA :  
SEKOLAH
 A L A M A T : Desa :  
Kecamatan :
JUMLAH SISA : La!"#La!"
: $%an&
Pe%em'an : $%an&
JUMLAH DOKTER KEIL * KKR : $
%an&
+URU YAN+ SUDAH DILATIH UKS : $%an&
RUAN+AN U KS : a ,a * t ",a! a ,a
-)

TAN++AL S URVEY :  

INDIKATOR PHBS SEKOLAH

No Uraian In dikator P HBS Ya Tidak Ket

. Mencuci Tangan dengan Air Bersi !

ang Menga"ir dan Me#akai Sa$un
a/ Sema !e0as mem"0"!" sa%ana cc" tan&an
,"0en&!a'" sa1n
1/ Sema s"s2a se0a0 me0a!!an cc"
tan&an 'a!a" sa1n ,"se!$0a3 (se1e0m
ma!an4 sete0a3 BAB ata set"a' tan&an !$t$%)
5 Mengkonsu#si %a%anan seat dikantin seko"a
a/ Se!$0a3 mem"0"!" !ant"n
1/ Kant"n se!$0a3 men6e,"a!an ma!anan
tan'a 'en&a2et ,an se0a0 te%tt'
se3"n&&a t",a!
,"3"n&&a'" 0a0at
c/ Sema s"s2a mem1e0" ,an men&!$nsms"
 7a7anan 6an& ,"se,"a!an ," !ant"n se!$0a3
8 Menggunakan %a#$an !ang $ersi dan seat
a/ Se!$0a3 mem"0"!" 7am1an sesa" ,en&an %at"$
 7m0a3 s"s2a
1/ Jam1an se!$0a3 te%'e0"3a%a (1e%s"3 ,an t",a!
1e%1a)
c/ Sema s"s2a men&&na!an 7am1an nt!
BAB ," se!$0a3
9 O"araga !ang teratur dan terukur 
Sema s"s2a me0a!!an a!t""tas ;"s"! ($0a3%a&a)
,en&an 2a!t ,an 7a,2a0 6an& ,"tent!an/ (a,a
!e&"atan senam se1e0m m0a" 1e0a7a% ,an ata
mas"n&#mas"n& s"s2a mem"0"!" 7a,2a0 'e0a7a%an
$0a3%a&a set"a' m"n&&)
< Me#$erantas %entik n!a#uk
 A,a !e&"atan se!$0a3 (s"s2a ,an &%) set"a'
m"n&&4 nt! mem1e%s"3!an 1a! man," ,an
'enam'n&an a"% 0a"nn6a4 ment'
'enam1n&an a"% ,an men&1% 1a%an& 1e!as
 No Uraian In dikator P HBS Ya Tidak

Tidak #erokok diseko"a =

T",a! a,a s"s2a ,an &% me%$!$! ," 0"n&!n&an se!$0a3 set"a' 3a%"
Meni#$ang $erat $adan dan >#engukur tinggi
$adan
 A,a !e&"atan s"s2a nt! men"m1an& 1e%at 1a,an ,an men&!% t"n&&" 1a,an ,"%an& UKS m"n"ma0 = 1
Me#$uang sa#&a &ada te#&atn!a
?
a/ Sema !e0as mem"0"!" tem'at 'enam'n&an sam'a3 sementa%a (1a! sam'a3)
1/ Sema s"s2a ,an &% se0a0 1an& sam'a3
'a,a tem'at sam'a3 (1a! sam'a3)

TOTAL SKOR

/////////////////4 //////////////////////////////////
Pet&as S%e6

( )

K%"te%"a K0as";"!as" PHBS se!$0a3 :

./ Se!$0a3 Se3at (K0as";"!as" B"%)4 B"0a sema "n,"!at$% PHBS Se!$0a3 (? "n,"!
at$% 
te%'en3" ata ,"7a2a1 @YA)
5/ Se!$0a3 K0as";"!as" H"7a4 B"0a "n,"!at$% PHBS 6an& te%'en3" (,"7a2a1 @YA) anta%a
=  > "n,"!at$%/
8/ Se!$0a3 K0as";"!as" Kn"n&4 B"0a "n,"!at$% PHBS 6an& te%'en3" (,"7a2a1 @YA) anta%a
9  < "n,"!at$%/
9/ Se!$0a3 K0as";"!as" Me%a34 B"0a "n,"!at$% PHBS 6an& te%'en3" (,"7a2a1 @YA) anta%a
.#8 "n,"!at$%/
 PENJELASAN INDIKATOR DAN PEN+ISIAN KUESIONER

N$ In,"!at$% De;"n"s" O'e%as"$na0 Pemen3an Kete%an&an

In,"!at$% 
. Mencc" Tan&an Se!$0a3 6an& ,"!ata! se!$0a3 Data ,"'e%$0e3
,en&an A"% Be%s"3 an memen3" "n,"!at$% memen3" "n,"!at$%4 ,en&an
6an& Men&a0"% Mencc" Tan&an ,en&an 1"0a !e,a "tem 'en&amatan
,an Mema!a" A"% Be%s"3 6an& Men&a0"% 'e%tan6aan (a ,an !e1e%a,aan sa
Sa1n ,an Mema!a" Sa1n a,a0a3 1) ,"7a2a1 @YA %ana cc"
se!$0a3 6an& : a/ mem"0"!" tan&an ,"set"a
sa%ana cc" '
tan&an 6an& ,"0en&! !e0as ,an
a'" menan6a!an
,en&an sa1n !e'a,a &% ,an
1/ sema s"s2an6a s"s2a ," mas"n&#
mem"0"!" mas"n& !e0as
!e1"asaan cc" tentan&
tan&an men&&na!an a"% !e1"asaan cc"
men&a0"%  tan&an
,an sa1n
se1e0m ma!an4 sete0a3
BAB ata set"a' tan&an !
$t$%/

5 Men&!$nsms" Se!$0a3 6an& Se!$0a3 Data ,"'e%$0e3

 7a7anan se3at ," memen3" "n,"! memen3" "n,"!at$%4 ,en&an
!ant"n se!$0a3 at$% men&! 1"0a !e,a "tem 'en&amatan
$nsms" 'e%tan6aan (a ,an !e1e%a,aan
 7a7anan se3at ," !ant"n 1) ,"7a2a1 @YA !ant"n ,an
se!$0a3 a,a0a3 se!$0a3 6an& : 'en6a7"an
a/ mem"0"!" !ant"n ma!anan
6an& men6e,"a!an ,"
ma!anan se3at tan'a !ant"n se!$0a3
'en&a2et ata'n ,an
'e2a%na 1e menan6a!an
%1a3a6a ,an !e'a,a &%4
men6a7"!an ma!anan 'en&e0$0a !
,en&an aman 'a,a ant"n
2a,a3 6an& 1e%s"3 ,an ,an s"s2a
te%tt' tentan&
1/ s"s2an6a men&! !e1"asaan
$nsms" ma!anan 6an&  7a7anan
se3at ," ,"se!$0a3
!ant"n se!$0a3/

8 Men&&na!an Se!$0a3 6an& Se!$0a3 Data ,"'e%$0e3

 7am1an 6an& 1e memen3" "n,"! memen3" "n,"!at$%4 ,en&an
%s"3 at$% men&&na! 1"0a !et"&a "tem 'en&amatan
,an se3at an 'e%tan6aan (a4 1 !$n,"s"
 7am1an 6an& 1e%s"3 ,an se3at ,an c) ,"7a2a1 @YA 7am1an se!
a,a0a3 se!$0a3 6an& : $0a3 ,an
a/ Se!$0a3 mem"0"!" menan6a!an
7am1an sesa" !e'a,a &%4
,en&an %at"$ ,an s"s2a
 7m0a3 s"s2a tentan&
1/ Jam1an se! !e1"asaan BAB
$0a3 te%'e0"3a%a (1e%s"3 s"s2a ,"se!
,an t",a! 1e%1a) $0a3
c/ Sema s"s2a
men&&na!an
7am1an
nt! BAB ," se!$0a3

9 O0a3%a&a 6an& te Se!$0a3 6an& !e&"atan Se!$0a3 memen3"

%at% ,an te%!%  memen3" "n,"!at$% $0a3%a&a senam "n,"!at$%4 1"0a "tem
6an& te%at%  se1e0m m0a" 'e%tan6aan te
1e0a7a% ,an %'en3" ata
,an te%!% a,a0a3 se!
$0a3 6an& s"s2an6a ata ,"7a2a1 @YA
me0a!!an a!t""tas ;"s"! mas"n&#mas"n&
($0a3%a&a) s"s2a mem"0"!"
,en&an 2a!t ,an  7a,2a0 'e0a7a
7a,2a0 6an& ,"tent!an %an $0a3%a&a
se'e%t" a,a set"a' m"n&&/
 Data ,"'e%$0e3
,en&an menan6a!an
!e'a,a &% ,an s"s2a
tentan&
 7a,2a0 $0a3%a&a
,"se!$0a3
N$ In,"!at$% De;"n"s" O'e%as"$na0 Pemen3an Kete%an&an
In,"!at$% 
< Mem1e%antas 7ent"! Se!$0a3 6an& memen3" Se!$0a3 memen3" Data ,"'e%$0e3
n6am! "n,"!at$% mem1e%antas 7ent"! "n,"!at$%4 1"0a "tem ,en&an
n6am! a,a0a3 se!$0a3 (s"s2a 'e%tan6aan te%se1t menan6a!an
,an &%) 6an& me0a!!an te%'en3" ata !e'a,a &% ,an
!e&"atan %t"n set"a' m"n&&4 ,"7a2a1 @YA s"s2a tentan&
nt! mem1e%s"3!an 1a! !e&"atan
man," ,an 'enam'n&an a"%  'em1e%antasan
0a"nn6a4 ment' sa%an& n6am!
'enam1n&an a"% ,an
men&1% 1a%an& 1e!as
," 0"n&!n&an se!$0a3/

= T",a! me%$! Se!$0a3 6an& Se!$0a3 Data ,"'e%$0e3

$! memen3" "n,"!at$% t",a! memen3" "n,"!at$%4 ,en&an
,"se!$0a3 me%$!$! 1"0a "tem 'e menan6a!an
,"se!$0a3 a,a0a3 se! %tan6aan te%se1t !e'a,a &% ,an
$0a3 te%'en3" ata s"s2a tentan&
,en&an s"s2a ,an &% ,"7a2a1 @YA !
6an& t",a! me%$!$! ," 0"n&! e1"asaan
n&an se!$0a3 set"a' 3a%"n6a/ me%$!$!
,"se!$0a3

> Men"m1an& 1e%at Se!$0a3 6an& Se!$0a3 Data ,"'e%$0e3

1a,an ,an men&! memen3" "n,"!at$% memen3" "n,"!at$%4 ,en&an
% t"n&&" 1a,an men"m1an& 1e%at 1a,an 1"0a "tem 'e 'en&amatan 'e
,an men&!% t"n&&" 1a,an %tan6aan te%se1t %a0atan
a,a0a3 se!$0a3 6an& me0a! te%'en3" ata ,"%an& UKS ,an
sana!an ! ,"7a2a1 @YA menan6a!an
e&"atan 'en"m1an&an 1e%at !e'a,a &% se
1a,an ,an 'en&!%an %ta s"s2a
t"n&&" 1a,an tentan& !
,"%an& UKS m"n"ma0 = e&"atan
10an se!a0" 'en"m1an&an
,an 'en&!%an
t"n&&" 1a,an
,"se!$0a3

? Mem1an& Se!$0a3 6an& Se!$0a3 Data ,"'e%$0e3

sam'a3 'a,a memen3" "n,"!at$% memen3" "n,"!at$%4 ,en&an
tem'atn6a mem1an& sam'a3 'a,a 1"0a !e,a "tem 'en&amatan
tem'atn6a a,a0a3 se!$0a3 'e%tan6aan te%se1t !e1e%a,aan 1a!
6an& : (a ,an 1) sam'a3 ," !
a/ mem"0"!" ,"7a2a1 @YA e0as4
!e1e%s"3an
tem'at 'enam'n&an 0"n&!n&an
sam'a3 sementa%a (1a! se!$0a3 ,an
sam'a3) menan6a!an
,"set"a' %an&an !e0as !e'a,a &% se
1/ S"s2a ,an &% %ta s"s2a
se0a0 1an& sam'a3 'a,a tentan&
tem'at sam'a3 (1a! !e1"asaan 1an&
sam'a3)4 se3"n&&a t",a! sam'a3
a,a sam'a3 1e%se%a!an
," 0"n&!n&an se!$0a3