REKAPITULASI HASIL SURVEY MAWAS DIRI ( SMD )

Desa : Tridarmayoga

Bila Ya, Apakah Apakah Anggota Bila Ya, Apakah Apakah Ada
Apakah Memiliki Bila Ya, Apa Sumber Apakah Memiliki
SAB Airnya Terlindung Jamban Jenis Jamban Keluarga (ART) yg Selama ini Minum Anggota Keluarga yg
A. Data Sehat Pernah Gangguan Jiwa Obat Dipasung
No Nama KK L/P Balita Bumil ∑ ART Keluarga

Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak

1 I gede rai sucita 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0

2 Ketut raket 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
3 I kadek sudiro 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
4 Ahmadi 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
5 Ketut yase swardana 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
6 Hery 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
7 I nengah suide 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
8 I nyoman wiradana 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
9 Putu dedi aryanto 1 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
10 I ketut suwardita 5 1 0 1 0 1 0 1 0 0 0 0 0 0 0
11 I nyoman fajar 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
12 I ketut sukoado 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
13 Made suka wijaya 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
14 Ketut sukarjo 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
15 made warsa 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
16 I nyoman sidiarta 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
17 Gusti nyoman ardika 1 5 1 0 1 0 1 0 1 0 0 0 0 0 0 0
18 Nyoman warnita 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
19 I kadek sumatra 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
20 I wayan sudarmono 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
21 Made roy rama sandy 1 6 1 0 1 0 1 0 1 0 0 0 0 0 0 0
22 Susanto 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
23 Sudirwan 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
24 Wayan weno 6 1 0 1 0 1 0 1 0 0 0 0 0 0 0
25 Made wilyadana yase 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
26 Kadek sukarja 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
27 Cecep sutruyatya 1 5 1 0 1 0 1 0 1 0 0 0 0 0 0 0
28 Made rapet 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
29 Ketut artana 6 1 0 1 0 1 0 1 0 0 0 0 0 0 0
30 Wayan yasa 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
31 Gede Ake 1 6 1 0 1 0 1 0 1 0 0 0 0 0 0 0
32 Wayan purwanta 1 5 1 0 1 0 1 0 1 0 0 0 0 0 0 0
33 Sri rahayu 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
34 Kasinem 2 1 0 1 0 1 0 1 0 1 0 0 0 0 0
35 Herman 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
36 Slamet 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
37 Aris wanto 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
38 Heri handri yanto 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
39 Suradi 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
40 Marsudi 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
41 Kadiman 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
42 Rubio 5 1 0 1 0 1 0 1 0 0 0 0 0 0 0
43 Made sutapa 3 1 0 1 0 1 0 1 0 0 0 0 0 0 0
44 Made sulastre 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
45 Andri anto 2 1 0 1 0 1 0 1 0 0 0 0 0 0 0
46 Wayan wiste 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
47 Suratman 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
48 Ketut arsane 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
49 Ketut sunantra 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
50 Nyoman wintara 1 1 4 1 0 1 0 1 0 1 0 0 0 0 0 0 0
51 Putu swantika 1 6 1 0 1 0 1 0 1 0 1 0 1 0 0 0
52 Sukamto 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
53 Jarwo 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
54 Nyoman dami yana 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
55 Nyoman bagio 1 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
56 Gde sutarsana 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
57 Putu agus stiawan 1 6 1 0 1 0 1 0 1 0 1 0 1 0 0 0
58 Gusti ngurah sumantra 1 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
59 Nyoman swardana 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
60 Gede karmadi 1 6 1 0 1 0 1 0 1 0 1 0 1 0 0 0
61 Wayan sudana 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
62 Pan siri 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
63 Agus suseno 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
64 Aep saifudin 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
65 I wayan sudarma 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
66 Kadek subagio 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
67 Wayan sudiro 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
68 Ketut sukarte 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
69 Made sujana 1 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
70 Nyoman badre 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
71 Made swarjana 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
72 Wayan urip 2 1 0 1 0 1 0 1 0 1 0 1 0 0 0
73 Nyoman widana 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
74 Ketut hary yanto 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
75 Ketut sane 1 6 1 0 1 0 1 0 1 0 1 0 1 0 0 0
76 Wahyu 6 1 0 1 0 1 0 1 0 1 0 1 0 0 0
77 Wayan suabe 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
78 Ketut gunawan 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
79 Made adi swarnata 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
80 Dw nyoman yana 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
81 Nyoman swambe 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
82 Made sudane 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
83 Ketut artana 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
84 Wayan widiane 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
85 Made sutama 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
86 Putu artanada 1 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
87 Komang triyana 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
88 Nyoman swardana 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
89 I wayan sukadana 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
90 Wayan manis 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
91 Wayan sudiasa 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
92 I gd sudanta 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
93 I nengah derem 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
94 I wayan sukadana 3 1 0 1 0 1 0 1 0 1 0 1 0 0 0
95 I ketut swartaye 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
96 Nyoman marno 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
97 Ketut sunade 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
98 Dewa aji armawa 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
99 I ketut swartaye 1 4 1 0 1 0 1 0 1 0 1 0 1 0 0 0
100 I wayan sukadana 1 5 1 0 1 0 1 0 1 0 1 0 1 0 0 0
 Apakah di Apakah di Bila Ya, mempunyai Pd kehamilan terahir, Pd Kehamilan Di keluarga anda, Di keluarga anda , Apakah Anak Apakah anak
Keluarga Bumil dimana 4-13 terakhir, Apakah ibu Terlahir terkhir ana
B. Berprilaku Keluarga Mempunyai rencana tempat Berlaku Apakah ibu melakukan mengalami gangguan Apakah Pernah Bila Ya, Apa Penyebabnya Apakah pernah memporel imun memperoleh
N0 Untuk Semua Mempunyai Balita Bumil melahirkan untuk 5 pemeriksaan min 4 x kehamilan terjadi kematian terlahir bayi BBLR lngkp imunisasi No
Umur tahun
terakhir
Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak

1 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1
2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2
3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3
4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4
5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5
6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6
7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7
8 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8
9 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 9
10 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10
11 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11
12 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 12
13 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13
14 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14
15 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15
16 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16
17 1 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 17
18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18
19 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 19
20 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20
21 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 21
22 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22
23 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23
24 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24
25 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 25
26 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26
27 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 27
28 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 28
29 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 29
30 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 30
31 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 31
32 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 32
33 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33
34 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34
35 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35
36 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36
37 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 37
38 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 38
39 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 39
40 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40
41 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 41
42 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42
43 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43
44 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 44
45 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 45
46 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 46
47 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 47
48 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48
49 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49
50 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 1 0 50
51 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 51
52 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 52
53 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53
54 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 54
55 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 0 1 0 55
56 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 56
57 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 57
58 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 58
59 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 59
60 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 60
61 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 61
62 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 62
63 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 63
64 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 64
65 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65
66 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 66
67 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 67
68 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 68
69 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 69
70 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70
71 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 71
72 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 72
73 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 73
74 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 74
75 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 75
76 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 76
77 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 77
78 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 78
79 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79
80 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 80
81 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 81
82 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 82
83 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 83
84 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 84
85 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 85
86 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 86
87 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 87
88 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 88
89 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 89
90 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90
91 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 91
92 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 92
93 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 93
94 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 94
95 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 95
96 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 96
97 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 97
98 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 98
99 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 99
100 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1 0 1 0 100
 Apakah Apakah keluarga Apakah Apakah anda Hipertensi Demem Berdarah, TBC, Gejala: Batuk
Dalam satu
dikelurga anda Apakah bayi anda keluarga anda menyimpan bilan Diare (gejala : ( Darah tinggi ) Gejala : Demam lama > 3 Minggu,
adna di berikan C. Gejala Pusing, tinggi mendadak Campak Pnemoni
ada bayi kurang ASI Eksklusif mengkonsumsi mengunakan garam terakhir Batuk pilek BAB Cair Tekanan darah disertai bintik-bintik Batuk berdarah, Gatal-gatal ( Gabagen ) ( Balita )
gizi/BGM/Buru selama 6 bln aneka ragam garam beryodium di Survailans >3kali/hari
apakah ada tinggi > 140/80 merah pada kulit, keringat dingin malam No
k menu makanan beryodium wadah tertutup , P2 dan anggota mmHg mimisan hari
PTM
kluarga
Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak yang sakit Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak

0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1
0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 2
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 3
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 4
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 5
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6
0 0 0 0 1 0 1 0 1 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 7
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 8
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 9
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 10
0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 11
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 12
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 13
0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 14
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 15
0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 16
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 17
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18
0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 19
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 20
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 21
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 23
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 24
0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 25
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 26
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 27
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 28
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 29
0 0 0 0 1 0 1 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 30
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 31
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 32
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 33
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 34
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 35
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 36
0 1 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 37
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 38
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 39
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 40
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 41
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 42
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 43
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 44
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 45
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 46
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 47
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 48
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 49
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 50
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 51
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 52
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 53
0 0 1 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 54
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 55
0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 56
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 57
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 58
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 59
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 60
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 61
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 62
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 63
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 64
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 65
0 0 0 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 66
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 67
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 68
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 69
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 70
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 71
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 72
0 0 0 0 1 0 1 0 1 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 73
0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 74
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 75
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 76
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 77
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 78
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 79
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 80
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 81
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 82
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 83
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 84
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 85
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 86
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 87
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 88
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 89
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 90
0 0 0 0 1 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 91
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 92
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 93
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 94
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 95
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 96
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 97
0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 98
0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 99
0 0 0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 100
 Apakah anggota Apakah anggota Apakah
Apakah ada keluarga anda terbiasa Apakah anggota keluarga anda Apakah keluarga keluarga anda Apakah Keluarga anda Apakah keluarga anda Apakah anda dan anggota Apakah ada anggota
E. Prilaku keluarga anda melakukan PSN melakukan aktifitas biasa membuka keluarga pernah berobat keluarga yg remaja
anggota keluarga mencuci tangan menggososk gigi 2x ( pmbrntsan srnag anda biasa BAB di biasa mencuci fisik olah raga min 30 jendela saat pagi hari ke puskesmas RI yang mndpat tablet
Anggota yg merokok dengan sabun sblum jamban tangan setlah
Keluarga sehari nymk ) min 1 x mnit stiap hari min stgh hari Ketapang FE No
makan ? seminnggu BAB
( Promkes )
Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak Ya Tidak

0 0 2 2 4 0 1 0 1 0 2 2 0 0 1 0 1 0 0 0 1
2 1 0 3 3 0 1 0 1 0 0 3 0 0 1 0 1 0 0 0 2
1 3 2 2 4 0 1 0 1 0 3 1 0 0 1 0 1 0 0 0 3
0 0 3 0 3 0 1 0 1 0 3 0 0 0 1 0 0 0 0 0 4
2 2 2 2 4 0 1 0 1 0 2 2 0 0 1 0 1 0 1 0 5
1 2 3 0 3 0 1 0 1 0 1 2 0 0 1 0 1 0 1 0 6
0 2 2 0 2 0 1 0 1 0 2 0 2 0 1 0 1 0 0 0 7
1 3 4 0 4 0 1 0 1 0 1 3 0 0 1 0 1 0 0 0 8
1 2 2 1 3 0 1 0 1 0 2 1 0 0 1 0 1 0 0 0 9
1 4 2 3 5 0 1 0 1 0 2 3 0 0 1 0 1 0 0 0 10
0 0 3 0 3 0 1 0 1 0 3 0 0 0 1 0 0 0 0 0 11
1 3 3 1 4 0 1 0 1 0 3 1 0 0 1 0 1 0 0 0 12
1 3 4 0 4 0 1 0 1 0 4 0 0 0 1 0 0 0 0 0 13
0 0 4 0 4 0 1 0 1 0 4 0 0 0 1 0 1 0 0 0 14
1 3 3 1 4 0 1 0 1 0 3 1 0 0 1 0 1 0 0 0 15
1 3 1 3 4 0 1 0 1 0 3 1 4 0 1 0 0 0 0 0 16
0 0 3 2 5 0 1 0 1 0 3 2 0 0 1 0 0 0 1 0 17
1 0 3 1 4 0 1 0 1 0 3 1 0 0 1 0 0 0 0 0 18
1 3 0 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 19
1 3 0 0 4 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 20
0 6 6 0 6 0 1 0 1 0 5 1 0 0 1 0 0 0 0 0 21
1 3 2 2 4 0 1 0 1 0 2 2 0 0 1 0 1 0 1 0 22
1 3 3 1 4 0 1 0 1 0 3 1 0 0 1 0 1 0 1 0 23
3 3 0 0 6 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 24
1 2 3 0 3 0 1 0 1 0 3 0 0 0 1 0 0 0 0 0 25
1 3 4 0 4 0 1 0 1 0 4 0 0 0 1 0 0 0 0 0 26
1 4 0 0 5 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 27
0 4 4 0 4 0 1 0 1 0 4 0 0 0 1 0 1 0 0 0 28
0 6 0 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 29
0 4 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 30
0 6 0 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 31
0 0 0 0 5 0 1 0 1 0 0 0 1 0 1 0 0 0 0 0 32
0 2 0 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 33
1 1 0 0 0 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 34
2 2 0 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 35
1 3 0 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 36
1 0 0 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 37
1 3 4 0 4 0 1 0 1 0 2 2 0 0 1 0 1 0 0 0 38
1 0 0 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 39
1 0 0 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 40
1 1 2 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 41
2 3 2 3 5 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 42
1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 0 1 0 43
0 4 4 0 4 0 1 0 1 0 4 0 0 0 1 0 0 0 0 0 44
1 1 2 0 2 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 45
1 3 3 0 3 0 1 0 1 0 3 1 0 0 1 0 0 0 0 0 46
0 4 4 0 4 0 1 0 1 0 4 0 0 0 1 0 0 0 0 0 47
0 0 4 0 4 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 48
0 4 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 49
1 3 4 0 4 0 1 0 1 0 1 0 0 0 1 0 1 0 0 0 50
0 6 6 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 51
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 52
2 2 4 0 4 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0 53
1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 54
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 55
1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 0 1 0 56
2 4 6 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 57
1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 58
0 4 4 0 4 0 1 0 1 0 2 2 0 0 1 0 0 0 0 0 59
1 5 6 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 60
0 0 4 0 4 0 1 0 1 0 3 1 0 0 1 0 0 0 0 0 61
1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 0 0 0 62
0 0 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 63
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 0 0 1 0 64
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 65
1 4 5 0 5 0 1 0 0 1 0 0 1 0 1 0 0 1 0 0 66
1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 67
0 5 5 0 5 0 1 0 1 0 5 0 0 0 1 0 0 1 1 0 68
1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 69
0 0 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 70
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 71
1 1 2 0 2 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 72
1 4 5 0 2 3 1 0 1 0 0 0 0 0 1 0 1 0 0 0 73
0 4 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 74
0 6 6 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 75
0 6 6 0 6 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 76
1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 77
0 0 3 2 5 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 78
1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 79
1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 80

1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 1 1 0 81

1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 1 1 0 82

1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 83

1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 84

2 3 5 0 5 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 85

1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 86

1 3 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 87

1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 0 1 0 0 88

1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 89

0 3 3 0 3 0 1 0 1 0 0 0 0 0 0 1 0 1 0 0 90

0 5 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 91

0 5 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 92

0 4 4 0 4 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 93

1 2 3 0 3 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 94

0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 00000000 95

3 2 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 96

2 3 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 97

1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 0 0 98

0 0 1 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0 00000000 99

1 4 5 0 5 0 1 0 1 0 0 0 0 0 1 0 1 0 1 0 100
 Apakah penyakit yg Apakah
Apakah terdapat Apakah lansia pernah dilalami oleh pekarangan sudah Bila Ya, apakah Apakah ada keluarga Jika Ada, Apakah Jika Ya, apakah
mendapatkan G. Hatra mengerti manfaat yg memiliki penyakit a. Mendapat Apakah dikeluarga ada
F. Posyandu lansia manfaat lansia a. hipertensi b. dimanfaatkan tanaman TOGA TBC b. Hipertensi c. kunjungan anak usia sekolah mendapatkan pelayanan
( Penyehat H.
Kesehatan di tempat anda posyandu lansia Rematik c. TBC d. untuk tanaman tersebut. DM d. Kolesterol rumah I. UKS kesehatan di UKS
Lansia Diabetes e. Lainnya.. Tradisional TOGA Perkesmas
)
Ya Tidak Ya Tidak a b c d e Ya Tidak Ya Tidak a b c d Ya Tidak Ya Tidak Ya Tidak

1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 1 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 1 0 0 0 0 0 1 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 0 0 0 0 1 0 1 0 0 1 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 1 0 1 0
1 0 1 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 1 0 1 1 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 0 0 1 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 0 0 0 0 1 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 0 1 0 0 0 1 0 1 0 0 0 0 1 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 1 0 1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1 0 1 0
1 0 0 0 0 0 0 0 0 1 0 1 0 0 0 0 0 0 0 1 0 1 0
1 0 1 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 1 0
 Berpakah Luas rumah Kualitas air yg di gunakan Kamar mandi yang Jenis kamar Lantai Kamar Mandi Pembuangan Sampah Rumah Pembuangan Air Limbah Jendela
keluarga yang di tempati sehari-hari dipakai keluarganya : mandi Tangga Rumah Tangga

a. Tersedia sarana
D. Rumah dan Luas : ……….. X …………= …… a. Tidak berasa, tidak bau,
jernih a. Ada, Mandi dirumah a. Terbuka a. Tanah a. Tersedia Tempat Pembuangan
Sampah yg terttp pembuangan tertutup dan a. Ada di seluruh jenis ruangan/
kamar dan cukup
mengalir
No Lingkungan b. Tidak Tersedia sarana No
( Kesling ) b. Tidak berasa, Berbau, b. Tersedia Tempat Pembuangan
Keruh b. ada, diluar rumah b. Tertutup b. Semen Sampah yg tdk terttp pembuangan tertutup dan b.Ada, Hanya sebagian ruangan
mengalir
c. Lainnya….. Sebutkan c. Tidak tersedia alasan
c. Tidak ada, alasan c. Ubin/Keramik c. tidak ada jendela
…………. …………………..

d. Lainnya, Sebutkan ……

a b c a b c a b a b c d a b c a b a b c
1 5x7 m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 1
2 6x9 m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 2
3 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 3
4 9x12 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 4
5 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 5
6 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 6
7 9x12m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 7
8 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 1 0 8
9 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 9
10 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 10
11 4x6 1 0 1 0 1 0 0 1 1 0 0 0 0 1 0 0 1 1 0 0 11
12 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 12
13 9x12m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 13
14 7x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 14
15 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 15
16 2x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 16
17 9x12m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 17
18 9x11m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 18
19 6x9m 1 0 0 1 0 0 1 0 0 1 0 0 0 0 1 0 1 1 0 0 19
20 6x9m 1 0 0 1 0 1 0 0 1 0 0 0 1 0 0 0 1 1 0 0 20
21 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 21
22 7x12 m 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 22
23 9x6m 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 23
24 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 24
25 6x9m 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 0 1 0 25
26 4x5m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 26
27 6,5x25m 1 0 0 1 0 0 1 0 0 1 0 0 0 1 0 1 0 1 0 0 27
28 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 28
29 5x6m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 0 1 0 29
30 6x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 30
31 2x5m 1 0 0 1 0 0 1 0 0 1 0 0 0 1 0 0 1 0 1 0 31
32 6x12m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 32
33 7x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 33
34 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 0 1 0 34
35 7x9m 1 0 0 0 1 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 35
36 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 0 1 0 36
37 7x9m 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 1 0 0 37
38 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 38
39 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 39
40 7x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 0 1 0 0 40
41 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 41
42 7x9m 0 1 0 0 1 0 0 1 0 1 0 0 1 0 0 0 1 1 0 0 42
43 5x7m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 43
44 5x7m 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 0 1 0 44
45 5x7m 1 0 0 1 0 0 0 1 0 1 0 0 1 0 0 1 0 1 0 0 45
46 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 46
47 8x8m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 47
48 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 48
49 10x6m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 49
50 5x7m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 0 1 0 50
51 7x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 51
52 6x7m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 52
53 5x7m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 53
54 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 54
55 10x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 55
56 10x11m 0 0 1 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 56
57 5x7m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 57
58 7x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 58
59 5x7m 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 1 0 0 59
1
60 7x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 60
61 10x12m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 61
62 9x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 62
63 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 1 0 0 1 0 63
64 10x10m 1 0 0 1 0 0 0 1 0 0 1 0 1 0 0 1 0 1 0 0 64
65 9x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 65
66 5x7m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 66
67 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 67
68 9x12m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 68
69 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 69
70 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 0 1 0 70
71 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 71
72 9x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 72
73 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 73
74 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 0 1 0 0 74
75 10x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 75
76 9x12m 0 0 1 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 76
77 7x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 77
78 7x14m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 1 1 0 1 0 0 78
79 12x12m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 79
80 9x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 80
81 9x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 81
82 12x12m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 82
83 6x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 83
84 9x9m 1 0 0 1 0 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 84
85 6x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 85
86 6x8m 1 0 0 0 1 0 1 0 0 1 0 0 0 1 0 0 1 1 0 0 86
87 10x12m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 87
88 7x10m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 88
89 7x10m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 89
90 7x9m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 1 0 0 90
91 6x9m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 91
92 7x14m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 92
93 6x9m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0 1 1 0 0 93
94 12x12m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 94
95 7x14m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 95
96 12x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 96
97 12x14m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 97
98 12x12m 1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 1 0 1 0 0 98
99 7x14m 1 0 0 1 0 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 99
100 7x10m 1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 1 0 1 0 0 100
 Ventilasi Lantai Rumah Atap rumah Langit-langit Rumah Kandang Ternak
(mayoritas Ruangan )

a. Ada Jendela, ada lubang angin a. Tanah a. Seng/Genteng a. Asbes a. Terpisah dari Rumah

b. Ada Jendela, Tidak ada lubang b. Menepel/menjadi satu

angin/ ventilasi b. Semen b. Anyaman Ijuk b. Triplex dengan rmh

c. Tidak ada jendela c. Ubin/Keramik c. Anyaman c. Tidak Punya

d. Lainnya….. d. Tanpa Langit2

a b c a b c d a b a b c d a b c
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 0 0 1
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 0 0 1
1 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 9 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 1 1 0 0 0 0 1 0 0 1
1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 1 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 1 0 0 0 1 0 0 0 1 0 1 0 0
1 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1
1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 1
1 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0
1 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 0 0 1
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 1 0 0 0 0 1
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 1 0 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 0 0 1
1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 0 0 1
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
0 1 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 1 0 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 1 0 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 0 1 0 1 0 0
1 0 0 0 1 0 0 1 0 1 0 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 0 1 0 0 1 0 0
1 0 0 0 1 0 0 1 0 0 0 0 1 1 0 0
1 0 0 0 0 1 0 1 0 1 0 0 0 1 0 0
1 0 0 0 0 1 0 1 0 0 0 1 0 1 0 0