Lampiran III-17-1.

A
DATA WARGA TP-
PKK

Dasa Wisma : ...................................................................

Nama Kepala
Rumah Tangga : ...................................................................
1. No. Registrasi : ...........................................................................
2. No. KTP/NIK : ...........................................................................
3. Nama : ...........................................................................
4. Jabatan : ...........................................................................
. Jenis Ke!amain : La"i La"i Peremp#an
$. Tempat La%ir : ..........................................................................
7. Tg!. La%ir / &m#r : '........../'......./'....... &m#r ' ..........Ta%#n
(. )tat#s Per"a*inan : +eni"a% La,ang Jana #a
. )tat#s a!am Ke!#arga : Kepa!a R#ma% Tangga Anggota Ke!#arga )tat#s ............................
10. Agama : Is!am Kristen Kat%o!i"  in# #%a K%ong%#%#
Keperaaan Lain ...................................................................................
11. A!amat : ......................................................................................................................
......................................................................................................................
esa/Ke!/)e,enis .............................................Ke......................................
Kab/Kota .........................................................Pro5. ...................................
12. Penii"aan : Tia" Tamat ) )/+I )+P/ )eera,at )+&/
)+K/)eera,at
ip!oma )1 )2 )3
13. Pe"er,aan : Petani Peagang )*asta 6ira#sa%a .....................
PN) TNI/Po!ri Lainna .............................................
14. A"septor K :  a Tia" Jenis Aseptor K .........................................
1. A"ti8 a!am "egiatan
Posan# :  a Tia" 9re"#ensi/ 5o!#me ..........."a!i/.....................
1$. +engi"#ti Program
ina K e!#arga a!ita : a Tia"
17. +emi!i"i Tab#ngan : a
Tia" 1(. +engi"#ti
Ke!ompo"e!a,ar : a Tia"
Jenis : Pa"et A Pa"et  Pa"et  K9
1. +engi"#ti PA&/
)e,enis : a Tia"
20. I"#t a!am
Kegiatan Koperasi : a Tia" Jenis Koperasi ........................................................
 Lampiran III-17-1.

KEGIATAN WARGA

AKTIVITAS KETERANGAN
NO KEGIATAN
(Y/T) (JENIS KEGIATAN YANG DIIKUTI)

Peng%aatan an Pengama!an

1.
Panasi!a
Ker,aba"ti
2.
3. R#"#n Kematian

4. Kegiatan Keagamaan

. Jimpitan

$. Arisan

7. Lain Lain
 Lampiran III-17-2A
DATA KE!ARGA
(Diisi oleh Kader, sumber kepala keluarga/ Kader)

asa 6isma .....................................................................................

RT. ''....R6 .....................#s#n/Ling"......................................
esa/Ke! ..............................Ke ...................................................
Kab/Kota...............................Pro5...................................................

 Nama Kepa!a R#ma% Tangga .................... ......................... .............

J#m!a% Anggota Ke!#arga......................................orang
La"i-La"i..............orang
Peremp#an.............orang
1. J#m!a% KK...............................................KK
2. J#m!a% :
a; a!ita .......... ana" < b; P&) .......... pasang < ; 6&) ........... orang < ; 3 #ta ........... orang < e; Ib# ami!......orang
8; Ib# +en#s#i ......... orang < g; Lansia........orang

NA#A STAT!S STAT!S $ENIS TG"

NO" NO" REG ANGGOTA D# DAA# KEA#IN A%IR/ PENDIDIKAN PEKER$AAN
KE!ARGA KE!ARGA PERKAWINA  P !#!R
N
1 2 3 4  $ 7 (  10

Status dalam keluarga : suami, istri, anak, menantu, keluarga, dll 

Status : kawin, tidak kawin

3. +a"anan Po"o" )e%ari-ari : eras Non eras Jenis... .... .... ....................................................
4. +emp#nai Jamban Ke!#arga : a PA+ Tia" J#m!a% ...''#a%
. : )#m#r )#ngai Lainna ...............................................
)#mber Air Ke!#arga
$.
+emi!i"i Tempat Pemb#angan
: a Tia"
7. )ampa%
+emp#nai )a!#ran Pemb#angan
Air Limba% : a Tia"
(. : A"ti8itasa&P2KTia" K#rang )e%at
+enempe! )ti"er P4K Kriteria R#ma%
. : Ling"#ngan
A"ti8itas Kegiatan &sa%a Kese%atan )e%at Tia" < Jenis &sa%a ..... ................ ..... ..... ..... ..... ...... ........ .
10. : a
11.
: a Tia" 
 Lampiran III-17 -
PE#AN&AATAN TANA% PEKARANGAN KE!ARGA

NO KATEGORI KO#ODITI $!#A%

'   *

 Kategori : [peternakan, perikanan, warung hidup, toga, tahaman keras,lainnya]

Lampiran III-17-
IND!STRI R!#A% TANGGA 2.

NO KATEGORI KO#ODITI V+lume

'   *

 Kategori : [pangan, sandang, konveksi, asa, lain!lain]

 Lampiran III-

DATA PEATI%AN KADER

(diisi kader yang telah mengikuti/ akti" dalam kegiatan #KK)

esa/Ke!............................................Ke . ............................................................................
Kab/Kota ..........................................Pro5. .............................................................................

1. No. Registrasi : .... . .. .... .... . ... .... ... ... ..... .. . .... .... .. . ..... .... .... .. . .... . .. .. . . .. .. .. .
2. Nama : ........... ..... .... ........... ........... .......... .......... ..... ........ .......
3. Tangga! +as#"/ )e,a" Ta%#n : ........./........../............. Ta%#n.. ............... ...............
4. Ke##"an / 9#ngsi : ...............................................................................
. Pe!ati%an ang perna% i i"#ti :

NO" NA#A PEATI%AN KRITERIA TA%!N PENYEENGGAR KETERANGA

KADER A N
'  * , 

 Kriteria kader : [diisi dengan kriteria kaderisasi]

 Keterangan : [diisi dengan berserti"ikat/tidak berserti"ikat]
 Lampiran 17-
ISIAN DATA ASET TP PKK DESA/ KE!RA
%AN
(diisi $#!#KK Kelurahan)

A" WAR!NG PKK

esa/Ke!..............................................Ke ....................................................................
Kab/Kota ............................................Pro5....................................................................

 Nama 6ar#ng PKK : .................. ................. .......................... ........ ......

 Nama Penge!o!a :................... ................. .......................... ........ ......
Komoiti ang i,#a! :

NO KO#ODITI KATEGORI VO!#E

'   *

 Kategori : [#alawia, %akanan #okok, dll]

 Lampiran 17
." TA#AN .AAAN

esa/Ke!.............................................. Ke ...................................................................

Kab/Kota ............................................ Pro5...................................................................

 Nama Taman aaan/ Perp#sta"aan : .......................... ......................... .....................

 Nama Penge!o!a : ............................ ......................... ..................... ........
J#m!a% #"# aaan...................b#"#
Jenis #"# aaan:

NO $ENIS .!K! KATEGORI $!#A%

'   *

 &umlah
 &enis buku : [$anaman hias, tanaman obat, ba'aan anak, dll]
 Kategori : [pertanian, #endidikan, ketrampilan keluarga]
 Lampiran 17

" KOPERASI

  esa/Ke!.............................................Ke ....................................................................
Kab/Kota ............................................Pro5....................................................................

$!#A%
STAT!S %!K!#
NO NA#A KOPERASI $ENIS KOPERASI ANGGOTA
.ER.ADAN .#" .ER.ADAN
 P
%!K!# %!K!#
'   * ,  0

 &enis Koperasi : [simpan pinam, usaha bersama, dll]

 Lampiran 17 -

D" KE$AR PAKET

esa/Ke!.............................................. Ke . .................................................................

Kab/Kota ............................................ Pro5. .................................................................

$ENIS PAKET $!#A% WARGA

NO NA#A KE$AR PAKET/ K&/ PA!D (A/.//K&/ PA!D) .EA$AR/ SISWA $!#A% PENGA$AR

 P P
'   * ,  0

J#m!a%
 Lampiran 17 -

E" POSYAND!

esa/Ke!.............................................. Ke ...................................................................

Kab/Kota ............................................Pro5....................................................................

 Nama Posan# : ........................ ......................... .......................... .......... ........

Penge!o!a : ................................................................................
)e"retaris : ................ ...... .......... .... .... .......... ...............................

Jenis Posan# : Pratama+aaP#rnama +aniriLansia

- J#m!a% Kaer :orang
- Jenis Kegiatan/ Laanan

$!#A%
KETERANGAN
&REKWENSI PET!GAS /
NO $ENIS KEGIATAN/ AYANAN AIN
AYANAN PENG!N$!NG
PARA#EDIS
PP
'   * ,  0 1
 Lampiran 17 -
 

&" KEO#POK SI#!ASI DAN PENY!!%AN

esa/Ke!.............................................. Ke ...................................................................

Kab/Kota ............................................Pro5....................................................................

$ENIS $!#A% $!#A% KADER

NO NA#A SI#!ASI /
KEGIATAN PENY!! KEO#POK SOSIAISASI  P
%AN
'   * ,  0