Form Monev Posyandu [PDF]

Citation preview

FORMAT MONITORING EVALUASI POS GIZI DI KOTA TANGERANG NAMA POS GIZI ALAMAT POS GIZI



: : KEL KEC



WILAYAH PUSKESMAS TANGGAL MONITORING DAN EVALUASI



: :



: :



A. SUMBER DAYA MANUSIA



NO



DESKRIPSI



1



KADER MINIMAL 5 ORANG



2



PETUGAS KESEHATAN DARI PUSKESMAS



3



STRUKTUR ORGANISASI



CHECKLIST ADA



TIDAK



URAIAN



B. PERALATAN DAN PERLENGKAPAN



NO



DESKRIPSI



1



PERALATAN MEMASAK



2



PERALATAN MAKAN DAN MINUM PESERTA



3



TEMPAT CUCI TANGAN



CHECKLIST ADA



TIDAK



URAIAN



NO



DESKRIPSI a.



AIR MENGALIR



b.



SABUN CUCI TANGAN



CHECKLIST ADA



TIDAK



URAIAN



FORMAT MONITORING EVALUASI POS GIZI DI KOTA TANGERA NAMA POS GIZI ALAMAT POS GIZI



: : KEL KEC



WILAYAH PUSKESMAS TANGGAL MONITORING DAN EVALUASI



NO



: :



DESKRIPSI



A.



SUMBER DAYA MANUSIA



1



KADER MINIMAL 5 ORANG



2



PETUGAS KESEHATAN DARI PUSKESMAS



3



STRUKTUR ORGANISASI



B.



PERALATAN DAN PERLENGKAPAN



1



PERALATAN MEMASAK



2



PERALATAN MAKAN DAN MINUM PESERTA



3



TEMPAT CUCI TANGAN



4



a.



AIR MENGALIR



b.



SABUN CUCI TANGAN



: :



PERLENGKAPAN ADMINISTRASI a.



KMS



b.



PAPAN ABSENSI



c.



ABSEN KADER



d.



ALAT PERMAINAN EDUKATIF (APE)



e.



FORM MONITORING BB PESERTA



f.



FORM MONITORING ASUPAN MAKANAN PESERTA



g.



MEDIA PENYULUHAN (LEMBAR BALIK/POSTER/DLL)



CHECKLIST ADA



TIDAK



NO 5



DESKRIPSI ALAT ANTROPOMETRI a.



DACIN



b.



TIMBANGAN ELEKTRIK



c.



ALAT UKUR PANJANG BADAN (UTK PESERTA < 2TH )



d.



MICROTOIS / ALAT UKUR TINGGI BADAN (UNTUK PESERTA > 2TH)



C.



PELAKSANAAN KEGIATAN



1



DAFTAR KELOMPOK BELANJA



2



DAFTAR KADER PENDAMPING



3



SIKLUS MENU 10 HARI a.



BERAGAM



b.



BERGIZI



c.



SEIMBANG



d.



AMAN



e.



MUDAH DIPRAKTEKKAN IBU PESERTA



6



PEMANTAUAN KESEHATAN OLEH PETUGAS KESEHATAN



7



PEMANTAUAN BERAT BADAN BALITA PESERTA



8



PEMANTAUAN KEBERSIHAN BALITA PESERTA b.



KEBERSIHAN KUKU



c.



KEBERSIHAN BADAN DAN PAKAIAN



9



PEMANTAUAN ASUPAN MAKANAN BALITA PESERTA



10



DILAKUKAN EDUKASI DAN PENYULUHAN a.



BALITA DIAJARKAN BERDOA SEBELUM DAN SESUDAH MAKAN



b.



BALITA DIAJAK BERMAIN SAMBIL MENUNGGU WAKTU MAKAN



c.



BALITA DAN IBU DIAJARKAN PERILAKU HIDUP BERSIH DAN SEHAT (PHBS)



CHECKLIST ADA



TIDAK



NO



DESKRIPSI



d.



CHECKLIST ADA



TIDAK



PENYULUHAN KESEHATAN DAN GIZI (JIKA YA SEBUTKAN)



D



KERJASAMA



1



KERJASAMA DAN KEKOMPAKAN ANTARA IBU BALITA



2



KERJASAMA IBU BALITA DENGAN IBU KADER DAN PETUGAS KESEHATAN



PERMASALAHAN DAN KENDALA YANG DIHADAPI :



..................................................................................................................................................................................................



..................................................................................................................................................................................................



..................................................................................................................................................................................................



..................................................................................................................................................................................................



.................................................................................................................................................................................................. ..................................................................................................................................................................................................



Mengetahui, Ketua Pos Gizi



(…………………………………………………………..)



ZI DI KOTA TANGERANG



URAIAN



URAIAN



URAIAN



......................................................................................



......................................................................................



......................................................................................



......................................................................................



...................................................................................... ......................................................................................



Petugas Monitoring & Evaluasi



(…………………………………………………………..)



Kop Puskesmas



LAPORAN HASIL MONITORING DAN EVALUASI KEGIATAN POSYANDU 1 Tanggal



: ..............................................................................................................................



2 Nama Posyandu



: ..............................................................................................................................



3 Alamat Posyandu



: ..............................................................................................................................



Kelurahan



: ..............................................................................................................................



Kecamatan



: ..............................................................................................................................



Wilayah Puskesmas



: ..............................................................................................................................



4 Hasil Monitoring



:



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



.............................................................................................................................................................................. 5 Kesimpulan / Saran Perbaikan



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



..............................................................................................................................................................................



Tangerang,



(.................................)



................



................



................



................



................



................



......................



......................



......................



......................



......................



......................



......................



......................



......................



......................



......................



......................