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 Ke!#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
2. Ker,aba"ti

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 PERKAWINAN  P !#!R 
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 Tia" J#m!a% ...''#a%
. )#mber Air Ke!#arga : PA+ )#m#r )#ngai Lainna ...............................................
$. +emi!i"i Tempat Pemb#angan
)ampa% : a Tia"
7. +emp#nai )a!#ran Pemb#angan
Air Limba% : a Tia"
(. +enempe! )ti"er P4K : a Tia"
. Kriteria R#ma% : )e%at K#rang )e%at
10. A"ti8itas &P2K : a Tia" < Jenis &sa%a .................................................................
11. A"ti8itas Kegiatan &sa%a
Kese%atan Ling"#ngan : a Tia"  
 

Lampiran III-17 -2.

PE#AN&AATAN TANA% PEKARANGAN KE!ARGA

NO KATEGORI KO#ODITI $!#A%

'   *

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

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

NO KATEGORI KO#ODITI V+lume

'   *

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

 

Lampiran III-17-3

DATA PEATI%AN KADER 

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

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

1. No. Regis tras i : .... .... .... .... ..... .... .... .... ..... .... .... .... .... ..... .... .... .... ..... .. .. .. .. .. .. .. .. .
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 KADER TA%!N PENYEENGGARA KETERANGAN

'   * , 

 Kriteria kader : [diisi dengan kriteria kaderisasi]

 Keterangan : [diisi dengan berserti"ikat/tidak berserti"ikat]
 

Lampiran 17-4.A

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 - 4.

." 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 - 4.

" KOPERASI

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

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

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

 

Lampiran 17 - 4.

D" KE$AR PAKET

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

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

$ENIS PAKET $!#A% WARGA

$!#A% PENGA$AR 
NO NA#A KE$AR PAKET/ K&/ PA!D (A/.//K&/ .EA$AR/ SISWA
PA!D)
 P  P
'   * ,  0

J#m!a%
 

Lampiran 17 - 4.=

E" POSYAND!

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

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

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

- Penge!o!a : .............................................................................................
- )e"retaris : .............................................................................................
- Jenis Posan# : Pratama +aa P#rnama +aniri Lansia
- J#m!a% Kaer : ..................... orang
- Jenis Kegiatan/ Laanan

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

Lampiran 17 - 4.9
 

&" KEO#POK SI#!ASI DAN PENY!!%AN

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

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

$ENIS $!#A% $!#A% KADER 

NO NA#A KEGIATAN SI#!ASI /
PENY!!%AN KEO#POK  SOSIAISASI  P

'   * ,  0