Form Pendaftaran Di Posyandu [PDF]

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LAMPIRAN I :



PERATURAN NOMOR TANGGAL



: : :



DAFTAR ISIAN DAFTAR POSYANDU NAMA Posyandu



:



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Alamat



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Jalan......................................................................................................



TR/RW



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Dusun/Lingkungan



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Desa/Kelurahan



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Kecamatan



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Kabupaten



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Provinsi



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Bulan



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Tahun



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Nama Pengisi



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Pekerjaan



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Jabatan



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SUMBER DATA UNTUK MENGISI DATA POSYANDU



1. ................................................................................................................................................................................................ 2. ................................................................................................................................................................................................ 3. ................................................................................................................................................................................................ 4. ................................................................................................................................................................................................



Nama & Tanda tangan



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PETUNJUK TEKNIS PENGISIAN DATA POSYANDU



I. PENCATATAN ‘MASTER POSYANDU’ Nomor Urut :................................ Diisi dengan angka latin yang menunjukkan nama sesuai dengan nomor urut seperti : 01, 02, 03, dan seterusnya. 2. Tahun ........................................... Diisi dengan tahun pendataan 3. Jenis Posyandu, dipilih strata posyandu 1.



Pratama Madya Purnama Mandiri Lain-lain 4. Nama Posyandu .............................................................................................................................. Diisi Nama Posyandu 5. Alamat Posyandu ........................................................................................................................... Diisi Alamat Posyandu 6. Penanggung jawab Umum .......................................................................................................... Diisi nama penanggung jawab umum 7. Penanggung jawab operasional ................................................................................................. Diisi nama penanggung jawab operasional 8. Ketua Pelaksana .............................................................................................................................. Diisi nama ketua pelaksana 9. Sekretaris ........................................................................................................................................... Diisi nama sekretaris 10. Jumlah kader posyandu ................................................................................................................ Aktif Tidak Aktif



........................................................................orang ........................................................................orang



11. Petugas Petugas KB Petugas Medis Bidan Desa



Ada/Tidak Ada/Tidak Ada/Tidak



12. Terintegrasi Program PAUD BKB Terpadu/Lainnya



Ada/Tidak Ada/Tidak Ada/Tidak



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II. PENCATATAN “DATA UMUM POSYANDU” 1. Tahun : ........................................................................................................................................................ Diisi dengan Tahun Pendataan. 2. Bulan : ........................................................................................................................................................... Diisi dengan Bulan Pendataan. 3. Jumlah Pengunjung Jml Bayi (0-11 bln) Jml Baduta (12-23 Bln) Jml Balita (24-59 Bln) WUS PUS Ibu



.................................................................................... Bayi .................................................................................... Bayi .................................................................................... Bayi .................................................................................. orang ............................................................................Pasangan Hamil ...................... Orang



Menyusui .................................Orang



4. Jumlah bayi Lahir Meninggal



.......................................................................Bayi .......................................................................Bayi



5. Jumlah Kematian Ibu Hamil, Salin, Nifas..................................................................................... orang 6. Jumlah Petugas Hadir Kader PKK Posyandu PLKB/PKB Medis dan Paramedis



........................................................................ orang ........................................................................ orang ......................................................................... orang



7. Jumlah Ibu Nifas Dapat Fe Dapat Vit A



........................................................................ orang ........................................................................ orang



8. Ibu Hamil KEK Anemia



....................................................................... orang ........................................................................ orang



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III. PENCATATAN KEGIATAN POSYANDU 1. Tahun ....................... Diisi dengan tahun pendataan 2. Bulan ....................... Diisi dengan bulan pendataan 3. Ibu Hamil Jumlah Ibu Hamil Jumlah Bumil yang Memeriksakan diri Jumlah yang mendapat Fe



........................................................................ orang ........................................................................ orang ........................................................................ orang



4. Jumlah Yang Menyusui : ............................ 5. Jumlah Peserta KB yang Mendapat Pelayanan Ulang KONDOM PIL SUNTIK



........................................................................ orang ........................................................................ orang ........................................................................ orang



6. Penimbangan BALITA Jumlah Balita (S) asaran Posyandu Jumlah BALITA punya (K) MS Jumlah BALITA (D)itimbabg BALITA (Naik) BB Jumlah BALITA (BGM) Jumlah BALITA BGM Laki-laki Jumlah BALITA BGM Perempuan



............................................................................... BALITA ............................................................................... BALITA ............................................................................... BALITA ............................................................................... BALITA ............................................................................... BALITA ............................................................................... BALITA ............................................................................... BALITA



7. Jumlah BALITA DAPAT VITAMIN A KMS YANG KELUAR Dapat Fe



...................................................................................... BALITA ....................................................................................... BALITA Fe-1 Fe-2 ..................... BALITA .............................. BALITA ..................................................................................... BALITA



BALITA Dapat PMT 8. Jumlah BALITA Yang Diimunisasi HEPATITIS 0-7 HARI BCG DPT- HB POLIO CAMPAK HEPATITIS TT



............................................................................ BALITA ............................................................................ BALITA I II III ........................ BALITA ....... BALITA ....... BALITA I II III IV .......... BALITA .......BALITA ....... BALITA ...... BALITA ................................................................................................. BALITA B-I B- II B- III ............... BALITA ............. BALITA ............... BALITA I II ................................... BALITA .................................. BALITA



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9. BALITA Yang Menderita DIARE Jumlah BALITA Diare Jumlah BALITA Dapat Oralit



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



BALITA BALITA



IV. PENCATATAN “ SARANA POSYANDU “ 1. Tahun : ................................ Diisi dengan tahun pendataan 2. Tempat Pelayanan Gedung Sendiri Menumpang Mebeleur



..................................................................................... Ada/ Tidak ..................................................................................... YA/ Tidak ..................................................................................... Ada/ Tidak



3. Jumlah Timbangan Bayi BALITA IBU



................................................................................................... Buah ................................................................................................... Buah .................................................................................................... Buah



4. Jumlah Buku Kesehatan Ibu dan Anak ............................................................................. Buah 5. Jumlah Formulir SIP ................................................................................................................ Buah 6.Jumlah Blanko SKDN ................................................................................................................ Buah 7. Jumlah Buku Catatan Keuangan .......................................................................................... Buah 8. Jumlah Alat Peraga Penuluhan ............................................................................................ Buah V. PENCATATAN “ PEMBINAAN POSYANDU” PER DESA 1. Tahun : ......................... Diisi dengaan tahun pendataan 2. Alokasi Dana APBN APBD Provinsi APBD Kabupaten/Kota APBD Desa Dana Masyarakat Dana Lain-lain



Rp ................................................................................... Rp ................................................................................... Rp ................................................................................... Rp ................................................................................... Rp ................................................................................... Rp ...................................................................................



3. Pembinaan Posyandu Menggunakan Kebijakan Gubernur Bupati/Walikota Camat Ka Desa/Lurah



Ya/Tidak Ya/Tidak Ya/Tidak Ya/Tidak



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