4.1.1-2 Kuisioner Identifikasi Kebutuhan & Harapan Masyarakat Promkes

IDENTIFIKASI KEBUTUHAN DAN HARAPAN MASYARAKAT

QUISIONER

Puskesmas Marowo

No Dok Dokum umen en

: 440/ 440/00 000/ 0/XI XII. I.20 2017 17/P /PKM KM.M .MR RW

No Revisi

:-

Tangg angga a Te!"i e!"i##

: $ Nove Novem" m"e! e! 2017 2017

%aaman

: 1 &a!i 1

Tan&a Tangan

:

PENGERTIAN

Me!u Me!u(a (aka kan n kegi kegia# a#an an i&en i&en#i #ii ika kasi si ke"u ke"u#u #u)a )an n &an &an )a!a )a!a(a (an n mas* mas*a! a!ak aka# a# # (!omo (!omosi si kese) kese)a#a a#an n *ang *ang &iak &iakuka ukan n &en &enga gan n 5a!a 5a!a mem" mem"e!i e!ikan kan (e!#an (e!#an* * *ang "e!)u"ungan &engan (!og!am P!omosi Kese)a#an

PROGRAM

PROMKES

PERTANYAAN

1 P!og!am P!omosi Kese)a#an Kese)a#an me!u(akan (!og!am kese)a#an *an (en*uu)an (e (em"inaan P% P% (e (em"i m"inaan 6K 6KM 3P 3Poskes&es P ain (em"inaan (em"inaan #em(a#-#em(a# #em(a#-#em(a# umum (em"inaan sa!ana sa!ana i"a&a) ke(a ke(a&a &a mas* mas*a! a!ak aka# a# #en# #en#an ang g kese kese)a )a#a #an n menu menu!u !u## an&a an&a (e! (e!uk uka) a) (

a. 'a ". Ti&ak 2 Menu!u# Menu!u# an&a an&a (e!u (e!uka) ka) &ia&aka &ia&akan n kegia kegia#an #an (en*uu (en*uu)an )an &i Mas*a!a Mas*a!a a. 'a ". Ti&ak - Jika Ya Ya Penyuluhan Penyuluhan kesehatan kesehatan tentang apa yang yang anda anggap anggap p .................................................... ............................................................................... .................................................. .......................   ......................................................................................................   ...................................................................................................... , Menu!u# an&a "agaimana se"aikn*a (en*uu)an &iakukan + a. e!kum(u &i kan#o! &esa &an &i"e!i a!a)an oe) ke(aa &esa ". Pa&a Pa&a saa# saa# Pos* Pos*an an&u &u ai ai#a #a &an &an an ansi sia a &i" &i"e! e!ii (en (en*u *uu u)a )an n oe oe) )( &an ka&e!  - Kalau Kalau tidak tidak berkena berkenan n denga dengan n salah salah satu satu jawa jawaban ban diatas diatas harap harap b .................................................... ............................................................................... .................................................. .......................   ......................................................................................................   ...................................................................................................... 4 Menu Menu!u !u## an& an&a a a(ak a(aka) a) (e! (e!u u &i &iak akuk ukan an Pem" Pem"in ina aan P% P% Ruma Ruma) )# a. 'a ". Ti&ak - Jika Tidak, sebutkan alasan anda:   ......................................................................................................   ......................................................................................................   ......................................................................................................  Menu!u# an&a a(aka) a(aka) (e!u &i"en#uk &an &iak#ikan kem"ai Desa a. 'a ". Ti&ak - Jika Tidak, sebutkan alasan anda:   ......................................................................................................   ......................................................................................................   ...................................................................................................... $ Menu Menu!u# !u# an& an&a a a(ak a(aka) a) (e! (e!u u menim menim"a "ang ng "ai "ai#a #a 3ana 3anak k umu! umu! 0- Ta) Ta) a. 'a ". Ti&ak - Jika Tidak, sebutkan alasan anda:   ......................................................................................................

  ......................................................................................................   ...................................................................................................... 7 Menu!u# an&a a(aka) (e!u &iakukan (em"inaan #em(a#-#em(a# u (i)ak kese)a#an + a. 'a ". Ti&ak - Jika Tidak, sebutkan alasan anda:   ......................................................................................................   ......................................................................................................   ...................................................................................................... RN 8 M6KN

a!an / Masukan an&a un#uk kegia#an (!og!am P!omosi kese)a#a ......................................................................................................   ......................................................................................................   ......................................................................................................   ......................................................................................................   ......................................................................................................   ......................................................................................................

Terima Kasih Atas Partisipasi anda

Jal!a Ta!er 

NIP.19$,0,11 190, 2 00 en#ang kegia#an (!og!am aaan ke(a&a mas*a!aka#

mem(un*ai kegia#an "e!u(a s*an&u Pos"in&u &an 6KM  enam"a)an (enge#a)uan og!am #e!se"u# &ia&akan +

a# +

rlu ? ......................................... ......................................... .........................................

e#ugas kese)a#an rikan usul anda: ......................................... ......................................... ......................................... angga &i mas*a!aka# +

......................................... ......................................... ......................................... iaga +

......................................... ......................................... ......................................... n &i Pos*an&u se#ia( "uan+

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

......................................... ......................................... mum &an #em(a# i"a&a) &a!i

......................................... ......................................... .........................................  &i mas*a!aka# : ......................................... ......................................... ......................................... ......................................... ......................................... .........................................