BERITA ACARA MONITORING (WITNESS

)
WILAYAH PROP/KAB

: ………………………………………

TGL/BLN/THN…………………..
NAMA RELAWAN : …………………………………..
HP…………………………………….
Telah dilakukan monitoring/ witness di Desa/Kel………………………....
dengan hasil sbb :
Waktu
Start
:
(WIB/WITA/WIT)
Selesai
:
(WIB/WITA/WIT)

TEMUAN WITNESS
A. Apakah surveyor benar mendatangi Kepala Desa / Lurah :
1. Ya
2. Tidak, alasan :
........................................................................................................
........................................................................................................
...................................................................
B. Apakah surveyor benar mendatangi Ketua RT /Dusun
/Lingkungan terpilih :
1. Ya
2. Tidak, alasan :
........................................................................................................
........................................................................................................
........................................................................
C. Apakah surveyor telah melakukan METODOLOGI (ANGKA
ACAK, KISGRID, SKIP PATERN ) dengan benar :
1. Ya
2. Tidak, alasan :
........................................................................................................
........................................................................................................
...................................................................
D. Apakah surveyor telah melakukan Wawancara dengan
responden dengan benar :
1. Ya
2. Tidak, alasan :
........................................................................................................
........................................................................................................
...................................................................

.................. Tidak.............................................................. ...................................................................................................................................................... .... ................................................. .................................................................................................................................................................................................................. alasan : ........................................................ Ya 2.................... Tidak............................................................. .......................................................................... Tidak.................................................... RELAWAN KADES LURAH / ....................... G.............................. Apakah etika / sopan santun dalam proses wawancara dengan responden telah dilakukan oleh surveyor : 1..................................................... alasan : ................ Temuan lain witness di lapangan : ........................E....................... .......................................... .................................................... F.................................... .......................................................................................... .................... Ya 2........................................................ ........................ ........................................................................................................................................................................................................................................................... Tindakan yang dilakukan : ................ .................................................................... Ya 2..................................................................................................................................... Apakah surveyor TIDAK memanipulasi data dilapangan ( cheating ) : 1............................................................................................................................................................ .......................................... ............................................... .................................... .................. alasan : ................. Apakah surveyor telah mengerjakan tugas yang telah ditargetkan : 1... ................................................ ....................................................................

--------------------------------------------------------(Dilengkapi dengan Stempel Lurah) .

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