FORMULIR PENILAIAN RUMAH SEHAT

NAMA .........................

ALAMAT KK:

1. ..............................

1 .....................................................

2. ..............................

2 .....................................................

3. ..............................

3 .....................................................

4. ..............................

4 .....................................................

5. ..............................

5 .....................................................

6. ..............................

6 .....................................................

7. ..............................

7 .....................................................

8. ..............................

8 .....................................................

9. ..............................

9 .....................................................

10. ..............................

10 .....................................................

KELURAHAN

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

KECAMATAN

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

KOTA

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

PROPINSI

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

TANGGAL

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

NAMA PETUGAS

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

NO
I

KOMPONEN RUMAH
YANG DINILAI
KOMPONEN RUMAH

3
4
5
6

8
II

SARANA SANITASI

KRITERIA

NILAI

BOBOT

HASIL PENILAIAN
(NO. KK)

4
III

PERILAKU PENGHUNI

5
TOTAL PENGHASILAN

CARA MENILAI HASIL PENILAIAN = Nilai x bobot