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  • RT: . RW: . Dusun: . Desa

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    Resna
    4 views6 pages
    This document appears to be a form for collecting data on households in a village, including information like: - Names of household heads and family members - Type of housing and building materials - Sources of clean water - Sanitation facilities - Waste disposal methods - Presence of livestock - Condition and features of the home The form includes columns to record details for multiple households, with categories like number of family members, type of house (permanent vs temporary), water source, toilet facilities, ventilation, and more. It aims to assess sanitation and living conditions across the village.

    Original Description:

    IS Rumah

    Original Title

    Frm Hasil Is

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    This document appears to be a form for collecting data on households in a village, including information like: - Names of household heads and family members - Type of housing and building materials - Sources of clean water - Sanitation facilities - Waste disposal methods - Presence of livestock - Condition and features of the home The form includes columns to record details for multiple households, with categories like number of family members, type of house (permanent vs temporary), water source, toilet facilities, ventilation, and more. It aims to assess sanitation and living conditions across the village.

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    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    4 views6 pages

    RT: . RW: . Dusun: . Desa

    Uploaded by

    Resna
    This document appears to be a form for collecting data on households in a village, including information like: - Names of household heads and family members - Type of housing and building materials - Sources of clean water - Sanitation facilities - Waste disposal methods - Presence of livestock - Condition and features of the home The form includes columns to record details for multiple households, with categories like number of family members, type of house (permanent vs temporary), water source, toilet facilities, ventilation, and more. It aims to assess sanitation and living conditions across the village.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
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    of 6

    FOMULI

    PUSKESMAS

    RT :………………………….
    RW :………………………….
    DUSUN :………………………….
    DESA :………………………….

    Jumlah Jenis Rumah Sarana Air Bersih

    NO Nama KK SGL
    1/2 lain +
    KK Jiwa G P SGL
    Gdg lain Pmp
    a

    1 2 3 4 5 6 7 8 9 10
    Daftar KK/Xls
    Keterangan :
    G : Gedung SGL : Sumur Gali
    1/2 G : Setengah Gedung SGL + Pompa Listrik
    P : Panggung PDAM : Perusaahaan Daerah Air Min
    Lain-lain : rumah yg tdk Layak Huni Mata Air : Sumber air dari mata air
    BT : Bebas Tikus Keadaan Rumah :
    TBT : Tdk Bebas Tikus WC + Cubluk : WC pakai spictank
    WC Tdk + Cubluk : Tdk Pakai sepitacn
    Lembab : di isi Lmbab
    Tidak : di isi tdk
    FOMULIR INPEKSI SANITASI (IS)RUMAH
    PUSKESMAS IMBANAGARA KECAMATAN CIAMIS

    Kdg
    Sarana Air Bersih Keadaan Rumah Tempat Sampah Hal Rmh
    Ternak

    WC
    MC WC
    Mat tdk Lban Lem Non
    PA K + Jend Vent Pdat/ SPA Orga Diba Terpi Tdk Bersi
    a + g b/Td Orga TPS
    M Um Cubl ela ilasi Tdk L nik kar sah TPS h
    Air Cubl Asap k nik
    um uk
    uk

    11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28
    SPAL Tert: Saluran Pembuangan Limbah pakai penampungan permanen tertutup
    Tempat Sampah Organik : Sampah yang diolah jadi Pupuk
    Daerah Air Min Non Organik : tidak bisa diolah jadi pupuk
    dari mata air Kandang Ternak Terpisah dari rumah
    Halaman rumah dimanfaatkan = ditanami apotek Hidup
    akai spictank BJ : Bebas jentiTBJ : Tidak bebas Jentik TPS : Tempat pembuangan sementara
    Ventilasi
    dk Pakai sepitacn : diisi MS atau MS SPAL : Diisi MS atau MS
    Padat Penghuni : Diisi padat atau Tidak MS : Memenuhi Syarat
    TMS : Tidak memenuhi syarat
    Hal Rmh Lantai Rmh Btng Pnlar Penykt

    Punya
    Rmh
    ASKIN/
    dima Tikus Jentik sehat
    Kera Tege Tana Papa Jmks
    nfaat
    mik l h n
    kan
    BT TBH BJ TBJ
    29 30 31 32 33 34 35 36 37 38 39
    Petugas Survei

    …………………………………………….

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