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Check List Akreditasi Program New
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PROGRAM P2P P2 P KUSTA DAFTAR TILIK SUPERVISI BIMBINGAN TEKNIS KEPADA PETUGAS KUSTA PUSKESMAS TANGGAL KUNJUNGAN
: ........................................................................
NAMA PUSKESMAS
: ........................................................................
NAMA PETUGAS YANG DI SUPERVISI
: ........................................................................
A. DATA DASAR 1.
JUML JUMLAH AH PENDU ENDUDU DUK K DI DI WIL WILY YAH PUSK PUSKE ESMAS SMAS
: ... ..... .... ........ .......... .......... ...... ........ .......... .......... ...... ........ .......... .......... .......... ...... ........ ......... ...
2.
JUMLAH DE DESA DI DI WIL WILAYAH PU PUSKESMAS
: .. ........................................................................
3.
JUMLAH DE DESA YA YANG AD ADA KA KASUS KU KUSTA
: .. ........................................................................
B. KELENGKAPAN PROGRAM P2P KUSTA Kelengkapan No
Kelengkapan Pemegang Program
Keerangan A!a
1
SK Pemeg Pemegan ang g Pr Prgr gram am P2P P2P KUS KUST TA
2
Ura!a Ura!an n "#ga$ "#ga$ %an T#&'$ #&'$!! Prgr Prgram am P2P P2P KUST KUSTA A
3
Da"a Da"a $a$a $a$ara ran n (Pr (Pr) )e' e'$! $! %an %an Rea Rea*+ *+
,
In%!' In%!'a" a"r r K!ne K!ner-a r-a SPM SPM Targe" arge" /a'#&a /a'#&an n
0
SP SP Pr Prgr gram P2P P2P KUS KUST TA
Kera Kerang ng'a 'a A# A#an an Pr Prgr gram am P2P P2P KUS KUST TA
4
Renan Renana a Ker-a Ker-a (RENJ (RENJA+ A+ Pr Prgr gram am P2P P2P KUST KUSTA A a. 5#*anan 6. Ta7#nan
8
Keg!a Keg!a"a "an n Yang Yang D!6! D!6!a) a)a! a! (JKN (JKN95 95K9A K9AP5D P5D9D* 9D**+ *+ a. RUK Prgram 6. RPK
/a"a" /a"a"an an Pe*a Pe*a'$ '$ana anaan an Pr Prgr gram am P2P P2P KUST KUSTA A a. Ja%;a* Keg!a"an Prgram P2P KUSTA 6. Kerang'a A#an Keg!a"an Prgram P2P KUSTA . 5#'< Pe*a'$anaan Keg!a"an Prgram P2P KUSTA 1. Per"em#an : Sr" Un%angan9 N"#*en9 Da=ar Ha%!r 2. 5#'an Per"em#an : S#ra" T#ga$ > Ha$!* 'eg!a"an 3. D'#men"a$! (P7" Tera"a" &a%a 6#'# ?!$#m+
1@ A%a #&a)a #&a)a mem!n! mem!n!ma*! ma*!$a$! $a$! re$!' re$!' &e*a'$anaa &e*a'$anaan n Keg!a"an "er7a%a& *!ng'#ngan *!ng'#ngan a. !%en<'a$! re$!' 6. Ana*!$!$ Re$!' . Penega7an %an mem!n!ma*!$!r re$!' re$!' %. e?a*#a$!
T"!ak
Kelengkapan No
Kelengkapan Pemegang Program
Keerangan A!a
T"!ak
B. La&ran %an RTL 11
Ha$!* K!ner-a (Ha$!* /a'#&an+ Prgram P2P KUSTA a. V!$#m 6. Pena"a"an %an &e*a&ran 'eg!a"an &er6#*an . Ha$!* /a'#&an &rgram &er6#*an &er"a7#n %. Gra' T!a& 5#*an e. Ana*!$a *a&ran
#. KETERAMPILAN DAN PENGETA$UAN PEMEGANG PROGRAM P2P KUSTA PETUGAS SUDAH DILATIH
: Ya
: T!%a'
Ta7#n :..............................
#ara Memperole' No.
$al %$al &ang D"n"la"
Pen"la"an "n(orma)"
A.
Pen"la"an Pengea'*an Pe*ga)
1.
Menge"a7#! /ar%!na* S!gn
Ya
T!%a'
Wa;anara
2.
Menge"a7#! Da$ar K*a$!'a$!
Ya
T!%a'
Wa;anara
3.
Menge"a7#! Reg!men MDT P5
Ya
T!%a'
Wa;anara
,.
Menge"a7#! Reg!men MDT M5
Ya
T!%a'
Wa;anara
0.
Menge"a7#! "an%aC"an%a rea'$!
Ya
T!%a'
Wa;anara
.
Menge"a7#! EBe' Sam&!ng MDT
Ya
T!%a'
Wa;anara
4.
Menge"a7#! EBe' Sam&!ng Pre%n!$n
Ya
T!%a'
Wa;anara
8.
Menge"a7#! !n%!'a$! R#-#'an
Ya
T!%a'
Wa;anara
a. Pen%er!"a %engan Pen)#*!"
Ya
T!%a'
Wa;anara
6. Pen%er!"a #n"#' re7a6*!"a$! Me%!$
Ya
T!%a'
Wa;anara
a. Pemer!'$aan $eara $!$"ema<$
Ya
T!%a'
6. Pemer!'$aan $eara *eng'a&
Ya
T!%a'
5enar
Sa*a7
B.
O+)er,a)" Keeramp"lan Pe*ga)
1.
Memer!'$a Pen%er!"a
. Te$ ma< ra$a &a%a 6era'
6$er?a$! Pe"#ga$
2.
%. Pera6aan SaraB
5enar$e%ang'#rang
e. Pemer!'$aan B#ng$! $araB ra$a ra6a
5enar$e%ang'#rang
B. Pemer!'$aan Ke'#a"an ""
5enar$e%ang'#rang
Mem6er! &en)#*#7an )ang $e$#a! a. Ke"era"#ran &eng6a"an
Ya
T!%a'
6. EBe' $am&!ng 6a"
Ya
T!%a'
Kelengkapan No
Kelengkapan Pemegang Program
Keerangan A!a
T"!ak
. Tan%a C "an%a rea'$!
Ya
T!%a'
%. Pera;;a"an %!n! (Pen%er!"a )ang /aa"+
Ya
T!%a'
3.
A&a'a7 &en)#*#7an %!menger< *e7 &en%er!"a
Ya
T!%a'
#.
Pen-aaan !an Pelaporan
1.
Kar"# Pen%er!"a a. /7ar
5enar
Sa*a7
6. Penen"#an T!ng'a" /a"a"
5enar
Sa*a7
Ya
T!%a'
5enar
Sa*a7
. Ke*eng'a&an &eng!$!an 2.
6$er?a$! Pe"#ga$;a;anara
6$er?a$! RR Wa;anara
Peng!$!an rma" PD a. Ke*eng'a&an Peng!$!an
6$er?a$! RR Wa;anara 6. 5era&a 'a*! $e*ama &eng6a"an 3.
................................
5#'# reg!$"er %an mn!"r!ng a. /ara &eng!$!an
5enar
Sa*a7
6. Ke*eng'a&an
Ya
T!%a'
. D!&!$a7'an '7r" &er"a7#n &er7a*aman
Ya
T!%a'
%. D!&!$a7'an '7r" P5 %an M5
Ya
T!%a'
5enar
Sa*a7
A%a
T!%a'
e. E?a*#a$! 7a$!* &eng6a"an
D.
Log")k
1.
/a"a"an &ener!maan9 &enge*#aran %an &er$e%!aan
6$er?a$! RR Wa;anara
MDTPre%n!$n 2.
Menge"a7#! ara meng7!"#ng 'e6#"#7an 6a"*g!$<'
Ta7#
T!%a'
3.
Per$e%!aan $e$#a! a"a"an
5enar
Sa*a7
,.
/ara &en)!m&anan
5enar
Sa*a7 6$er?a$! RR Wa;anara
0.
P$"er
A%a :.......
T!%a'
.
Leae"
A%a :.......
T!%a'
4.
rm PD
A%a :.......
T!%a'
8.
rm Pre%n!$n
A%a :.......
T!%a'
.
5#'# Pe%man
A%a :.......
T!%a'
E.
Pelaporan Ke Ka+*paen
1.
Se$#a! Ja%;a*
Ya
T!%a'
2.
/ara Peng!$!an
5enar
Sa*a7
3.
Ke*eng'a&an
Ya
T!%a'
F.
Daa Pokok
Ya
T!%a'
6$er?a$! RR In"er?!e;
6$er?a$! RR In"er?!e;
Kelengkapan No
Kelengkapan Pemegang Program
Keerangan A!a
T"!ak
MASALA$/
$AMBATAN /
USUL 0 SARAN/
Menge"a7#! Ke&a*a P#$'e$ma$ ..................................................
Wa$r Prgram P2P K#$"a D!na$ Ke$e7a"an Ka6#&a"en 5gr
...............................................................................
a!$a* Ir7am Am%.Ke&
...............................................................................
NR.PTT. 2@@@,23
C
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