Tahun 2021
Kabupaten :
Puskesmas :
1 2 3 4 5 6 7 8 9
Angka 1 jika
posyandu buka ≥7 JUMLAH
Jan KET Feb KET Mar KET Apr KET Mei KET Jun KET Jul KET Ags KET Sep KET Ok KET Nov KET Des KET kali, Angka 0 jika KADER
posyandu buka POSYANDU
<10 kali
TOGA, Penanggulangan penyakit atau kegiatan tambahan kesehatan lain sesuai dengan kebutuhan dan kesepakatan masyarakat, Jika Ya diisi = 1 dan Jika Tidak Diisi = 0
Kolom 13 : Diisi Jenis, Jumlah dan Kondisi alat pemantauan Pertumbuhan dan perkembangan yang dimiliki Posyandu
Kolom 14 : Diisi Ya atau Tidak Posyandu melakukan sekurang-kurangnya 1 kegiatan pengembangan seperti kesehatan remaja, kesehatan usia kerja, kesehatan lanjut usia,
10
Angka 1 jika
jumlah kader
≥5, angka 0 jika Cakupan Ya/ Tidak Cakupan Ya/ Tidak Cakupan Ya/ Tidak
jumlah <5
Angka 1 jika Angka 1 jika Angka 1 jika
Gizi (D/S) Imunisasi=…
KIA = ….% cakupan ≥50%, KIA = ….% Gizi (D/S) =…..% Imunisasi=…....% cakupan ≥50%, KIA = ….% Gizi (D/S) =…..% Imunisasi=…....% cakupan ≥50%,
=…..% ....% KB = …...% angka 0 jika KB = …...% angka 0 jika KB = …...% angka 0 jika
cakupan <50% cakupan <50% cakupan <50%
1 40 0 60 1 50 1 100 1 1 100 1 100 1 100 1 100 1 1 100 1 100 1 100 1 100 1 1
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LAPORAN KABUPATEN/KOTA
INDIKATOR PRESENTASE KABUPATEN KOTA DENGAN MINIMAL 80 % POSYANDU AKTIF
TRIWULAN I TA 2021
KRITERIA 3 :
Cakupan minimal 50% sasaran posyandu mendapatkan masing-masing layanan KIA, Gizi, Imunisas
11
11
Cakupan Ya/ Tidak Cakupan Ya/ Tidak Cakupan Ya/ Tidak Cakupan
Memenuhi
kriteria jika≥ 8
kali dalam 1
Cakupan Ya/ Tidak Cakupan Ya/ Tidak Cakupan Ya/ Tidak tahun terisi Ya
atau 1
Angka 1 jika Angka 1 jika Angka 1 jika
Gizi (D/S) =…..% Imunisasi=…....% cakupan ≥50%, KIA = ….% Gizi (D/S) =…..% Imunisasi=…....% cakupan ≥50%, KIA = ….% Gizi (D/S) =…..% Imunisasi=…....% cakupan ≥50%,
KB = …...% angka 0 jika KB = …...% angka 0 jika KB = …...% angka 0 jika
cakupan <50% cakupan <50% cakupan <50%
100 1 100 1 100 1 1 100 1 100 1 100 1 100 1 1 100 1 100 1 100 1 100 1 1 1
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KRITERIA 4 : KRITERIA 5: POSYANDU AKTIF Strata
posyandu memiliki alat pemantauan pertumbuhan dan Posyandu melakukan sekurang-kurangnya 1 (jika semua kriteria Posyandu
perkembangan berupa alat timbang berat badan dan tinggi badan kegiatan pengembangan seperti kesehatan remaja, terpenuhi) ( 1. Pratama,
serta alat ukur perkembangan kesehatan usia kerja, kesehatan lanjut usia, TOGA, 2. Madya,
Penanggulangan penyakit atau kegiatan tambahan
kesehatan lain sesuai dengan kebutuhan dan 3. Purnama,
kesepakatan masyarakat 4. Mandiri )
13 14 15 16 17 18
Alat
Kondisi
Alat Ukur Alat ukur (tulis : Angka 1 jika memiliki Tulis Angka 1 jika Angka 1 jika semua
Timbang Tinggi Perkemban baik , alat timbang, alat ukur Nama Kegiatan memiliki kegiatan kriteria terpenuhi.
Berat Badan Badan (1 gan (1 = tinggi dan alat ukur Pengembangan (tulis : pengembangan. Angka 0 Angka 0 jika salah
Pinjam
(1 = ada, = ada, ada, 0=tdk atau perkembangan. Angka nama kegiatannya) jika tidak memiliki satu kriteria tidak
0=tdk ada) 0=tdk ada) 0 jika tidak memenuhi. kegiatan pengembangan. terpenuhi
ada) rusak)
Tahun : xxxx
Nama Provinsi : xxxx
Nama Kab/Kota : xxxx
Jumlah Sasaran Jumlah Petugas Kesehatan Puskesmas yang Telah Dilatih/Diorientasi KAP
Jumlah Sasaran
No Kab/Kota Puskesmas Petugas Kesehatan Puskesmas Kader yang akan Jumlah Kader yang Telah
yang akan Dilatih/Diorientasi Dilatih/Diorientasi KAP Dilatih/Diorientasi KAP
KAP Bidan Perawat Gizi Promkes Sanitasi/Kesling
1 2 3 4 5 6 7 8 9 10 11
1 zzzz zzzz 50 10 5 5 5 5 50 25
xxxx 45 7 5 5 5 5 35 25
LOKUS KEGIATAN IMPLEMENTASI KOMUNIKASI ANTAR PRIBADI OLEH PETUGAS KESEHATAN (BIDAN, PERAWAT, GIZI, 70% DESA
DESA/KELURAHAN
NO KAB/KOTA KECAMATAN STUNTING PROMKES, SANITASI) ATAU KADER REKAPITULASI MELAKUKAN KAP
TAHUN LANGKAH 4 STBM/ KELAS IBU KELAS IBU PLA KUNJUNGAN PENYULUHAN (1 = Ya; 0 =Tidak)
NAMA STATUS KONSELING
POSYANDU PEMICUAN HAMIL BALITA MALARIA RUMAH KELOMPOK
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16