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DINAS KESEHATAN KABUPATEN JEMBER FORM INSTRUMEN MONITORING EVALUASI PELAYANAN KESEHATAN TRADISIONAL



PUSKESMAS TIM TANGGAL PELAKSANAAN MONEV



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1 Register Pelayanan Kesehatan Tradisional; 2 Laporan Bulanan Pelayanan Kesehatan Tradisional Proses a. Pembinaan ke Penyehat Tradisional Output Jumlah Penyehat Tradisional di Wilayah (Ketrampilan dan Ramuan) 3 a. Ketrampilan b. Ramuan Penyehat Tradisional yang mempunyai STPT (Surat Terdaftar Penyehat Tradisional) dilengkapi dengan bukti STPT penyehat tradisional 4 a. Penyehat Tradisional Keterampilan yang memiliki STPT b. Penyehat Tradisional ramuan yang memiliki STPT Kelompok Asuhan Mandiri yang terbentuk (dilengkapi dengan Bukti SK dari Desa/Kelurahan) a. Nama Kelompok Asman (Asuhan Mandiri) :



5 b. Nomor SK Desa/Kelurahan Kelompok Asman (Asuhan Mandiri) :



6 Panti Sehat berkelompok yang berijin 7 Fasilitas Pelayanan Kesehatan Tradisional berkelompok yang berijin Permasalahan ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. Kesimpulan Hasil Monitoring dan Evaluasi ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. Rencana Tindak Lanjut ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. ................................................................................................................................................................................. .................................................................................................................................................................................



Koordinator Yankestrad Puskesmas



Petugas Monev



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