IDENTITAS RESPONDEN

NO PROMOSI KESEHATAN
RESPONDEN UMUR SEX PENDIDIKAN PEKERJAAN 1 2 3
L P A B C D E F G A B C D E F G A B C D E A B C D E A B C D E

1 40 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0
2 50 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
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5 42 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
6 46 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
7 39 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
8 55 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
9 48 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
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13 65 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
14 42 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
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16 31 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
17 60 0 1 0 0 0 0 0 0 1 1 0 0 0 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0
18 21 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 1 0 0
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21 26 1 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1
22 48 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
23 50 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1
24 53 1 0 0 1 0 0 0 0 0 0 0 1 0 0 0 0 1 1 1
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29 67 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
30 36 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1
31 57 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1
32 54 0 1 0 0 1 0 0 0 0 0 0 0 0 1 0 0 1 1 1
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34 63 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
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45 39 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
46 48 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
47 59 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
48 17 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
49 38 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
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51 33 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
52 50 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
53 46 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
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56 32 0 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 1 1
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63 55 0 1 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
64 64 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1
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80 43 1 0 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
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111 18 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
112 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1
113 23 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
114 36 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1
115 23 1 0 0 1 0 0 0 0 0 0 1 0 0 0 0 1 1 1
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117 39 1 0 0 0 1 0 0 0 0 0 0 0 0 0 1 1 1 1
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119 40 1 0 0 0 1 0 0 0 0 0 0 1 0 0 0 1 1 1
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128 50 1 1 0 0 0 1 1 1 1
129 32 1 1 0 0 0 1 1 1 1
130 43 1 1 0 0 0 1 1 1 1
131 40 1 1 0 0 0 1 1 1 1
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133 33 1 1 0 0 0 1 1 1 1
134 46 1 1 0 0 0 1 1 1 1
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142 45 1 1 1 1 1 1
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173 41 1 1 1 1 1 1
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181 48 1 1 1 1 1 1
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SEHATAN KESEHATAN LINGKUNGAN
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3 50 25 154 7 3 58 34 139 5 6 84 33 115 3 2 7 67 154 9 4 69 43 117 6 1 37 72 121 8 46 113 10 55 22

 LANSIA
46 47
A B C D E A B C D E A B
1 1
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INDRA (MATA) PERKESMAS
48 49 50 51 52
C D E A B C D E A B C D E A B C D E A B C D E
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4 57 19 154 3 5 88 24 118 2 3 65 27 139 5 1 26 12 196 4 1 64 23 149 2 1 24 34 175 5 4 22 28 175 9

PERKESMAS HATRA
53 54 55
MASUKAN / USULAN
A B C D E A B C D E A B C D E

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1 TOLONG MUSHOLA
1 DI PUSKESMAS DIAKTIFKAN,
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EHATIKAN, TAMBAH LOKASI RUANGAN

H JARANG DILAKUKAN SEPERTI DULU, AGAR PENYAKIT DBD TIDAK TIMBUL DI MASYARAKAT
E RUMAH RUMAH WARGA , AGAR MENGERTI YG TERKENA PENYAKIT MENULAR DAN TIDAK MENULAR
 IDENTITAS RESPONDEN
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L P A B C D E F G A B C D E F G A B C D E A B C D E A B C D

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E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D E A B C D

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0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0 0 0 0 0 1 0 0 1 0 0
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0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 1 0 0 0
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14 3 50 25 154 7 3 58 34 139 5 6 84 33 115 3 2 7 67 154 9 4 69 43 117 6 1 37 72 121 8 46 113 10 55

 LANSIA
45 46 47
E A B C D E A B C D E A
1 1
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INDRA (MATA) PERKESMAS
48 49 50 51 52
B C D E A B C D E A B C D E A B C D E A B C D
1 1 1 1 1
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0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
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0 0 0 1 0 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1
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0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
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0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 0 1
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0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0 0 0 0 1
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22 4 57 19 154 3 5 88 24 118 2 3 65 27 139 5 1 26 12 196 4 1 64 23 149 2 1 24 34 175 5 4 22 28 175

 PERKESMAS HATRA
52 53 54 55
MASUKAN / USULAN
E A B C D E A B C D E A B C D E

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1 1 1 PELAYAN KURANG RAMAH SEDIKIT
1 1 1 PELAYANAN DITINGKATKAN JANGAN PILIH PILIH,KEBERSIHAN RUANGAN DIPEHATIKAN, TAMBA
1 1 1
1 1 1 SEHARUSNYA FOGING DILKUKAN LEBIH GIAT LAGI KARENA SEKARANG SUDAH JARANG DILAK
1 1 1 SEHARUSNYA PEGAWAI PUSKESMAS MELAKUKAN PEKERIKSAAN KELILING KE RUMAH RUMAH
1 TOLONG MUSHOLA
1 DI PUSKESMAS DIAKTIFKAN,
1 TEMPAT WUDU DI PERBAIKI, TOILET DI RUANG PASIEN TOLONG DIBERSIHKAN
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0 0 1 0 0 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 1 0 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0
0 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0
0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
0 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0
1 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
1 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0
0 1 0 0 1 0 1 0 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0
0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 1
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
1 0 0 0 0 1 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 1 0 0 0 0 0 1 0
0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 0 1 0 0 0 0 1 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0
0 0 0 1 0 0 0 0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 1 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 1 0 0 0 0 1 0 0
0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 1
0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0 0 0 0 1 0 0 0
0 0 0 0 1 0 0 0 0 1 0 0 0 0 1 0
0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0

9 1 8 12 174 43 2 44 65 118 8 2 70 49 109 6

 HASIL SURVEY KEBUTUHAN DAN HARAPAN MASYARAKAT

INDEKS %
NO DT DT SURVEY STS TS N S SS T. SKOR KESIMPULAN
(TS/Yx100)

A Program Promosi Kesehatan

1 Apakah menurut saudara Desa Siaga perlu diaktifkan ? 1 1 10 160 68 1013 84.42 Sangat perlu
2 Apakah menurut saudara pelaksanaan kegiatan Desa siaga sudah sesuai ? 5 49 63 118 4 784 65.33 Sesuai
3 Apakah pelaksanaan Survey Mawas Diri (SMD) sudah sesuai dengan yang diharapkan ? 3 32 74 124 7 820 68.33 Sesuai
4 Apakah saudara mengetahui manfaat Musyawarah Masyarakat Desa (MMD) di desa ? 3 83 27 122 4 758 63.17 Tahu
Apakah menurut saudara tindak lanjut kegiatan dari hasil Musyawarah Masyarakat Desa
5 3 10 22 162 43 952 79.33 Perlu
(MMD) perlu dilakukan ?

B Program Kesehatan Lingkungan

6 Apakah saudara mengetahui jenis-jenis sarana air bersih ? 2 16 12 179 31 941 78.42 Tahu
7 Apakah saudara mengetahui syarat air minum yang memenuhi syarat kesehatan ? 2 9 13 186 30 953 79.42 Tahu
8 Apakah saudara mengetahui jarak antara sumur dengan jamban/WC 14 23 16 173 12 860 71.67 Tahu
Apakah saudara setuju apabila pembuangan air limbah Dibuatkan saluran dan ditampung
9 3 9 10 133 85 1008 84.00 Sangat setuju
pada tempat tertutup ?
10 Apakah menurut saudara perlu ada pemilahan sampah organik dan unorganik ? 3 0 23 153 62 994 82.83 Sangat perlu

C Program Perbaikan Gizi

Apakah Saudara mengetahui bahwa makanan tambahan pada bayi diberikan setelah bayi
11 2 19 16 148 53 945 78.75 Tahu
berumur 6 bulan ?
12 Apakah saudara mengetahui bahwa di Puskesmas ada konseling menyusui ? 2 66 29 136 7 800 66.67 Tahu
13 Apakah saudara mengerti tentang manfaat kapsul vitamin A untuk anak balita ? 1 21 23 160 36 932 77.67 Mengerti
14 Apakah Saudara membutuhkan pelayanan gizi di posyandu ? 1 4 21 131 84 1016 84.67 Sangat butuh
15 Apakah ibu hamil perlu minum tablet tambah darah ? 1 12 32 133 63 968 80.67 Sangat perlu

D Program Kesehatan Ibu dan Anak (KIA) dan Keluarga Berencana (KB)

Apakah Saudara mengetahui bahwa pemeriksaan ibu hamil, bayi, tumbuh kembang dan
16 1 7 11 172 50 986 82.17 Sangat tahu
imunisasi merupakan pelayanan kesehatan ibu dan anak ?
 INDEKS %
NO DT DT SURVEY STS TS N S SS T. SKOR KESIMPULAN
(TS/Yx100)
Apakah menurut saudara perlu menambah jenis pelayanan kesehatan ibu dan anak di
17 1 4 27 175 34 960 80.00 Sangat perlu
Puskesmas ?
Apakah saudara setuju bila melahirkan di Tenaga kesehatan(Bidan/Dokter) lebih aman
18 3 1 11 130 95 1033 86.08 Sangat setuju
daripada di dukun ?
Apakah Saudara mengetahui apabila terdapat ibu hamil Kurang Energi Krinik (KEK) dan
19 1 7 33 166 34 948 79.00 Tahu
balita Kurang Energi Protein (KEP) dirujuk kmana ?
Apakah menurut saudara dapat dilakukan dengan mudah untuk mendapatkan pelayanan
20 1 3 27 158 61 1025 85.42 Sangat mudah
keluarga berencana (KB) di Puskesmas ?
21 Apakah saudara tahu jenis-jenis kontrasepsi KB ? 4 28 22 152 36 914 76.17 Tahu

E P2 TB-PARU

22 Apakah saudara mengetahui tanda tanda penyakit TBC Paru ? 3 55 17 160 5 829 69.08 Tahu
Apakah saudara setuju bahwa batuk darah merupakan salah satu tanda-tanda penyakit TBC
23 2 11 24 181 22 930 77.50 Setuju
Paru ?
24 Apakah saudara mengetahui tempat pelayanan TBC Paru ? 1 46 22 165 6 849 70.75 Tahu

F HIV AIDS

Apakah Saudara mengetahui penyakit HIV/AIDs adalah penyakit menular berbahaya dan
25 1 22 16 171 31 932 77.67 Tahu
belum ada obatnya ?
Apakah saudara setuju bahwa penularan penyakit HIV/AIDs salah satunya melalui hubungan
26 2 19 9 133 77 984 82.00 Sangat tahu
sex ?
Apakah saudara setuju bahwa berenang bersama-sama dapat menularkan penyakit
27 7 71 72 85 5 730 60.83 Setuju
HIV/AIDs ?

G DBD
28 Apakah saudara mengetahui tentang penyakit Demam Berdarah (DBD) ? 2 15 13 190 21 936 78.00 Tahu
29 Apakah saudara mengetahui tempat berkembangnya nyamuk Demam Berdarah (DBD) ? 1 18 4 195 23 944 78.67 Tahu
30 Apakah PSN diperlukan untuk memberantas nyamuk Demam berdarah (DBD) ? 2 6 18 115 98 1018 84.83 Sangat perlu

H Malaria
 INDEKS %
NO DT DT SURVEY STS TS N S SS T. SKOR KESIMPULAN
(TS/Yx100)
31 Apakah menurut saudara mengetahui penyebab penyakit malaria ? 3 40 16 171 10 865 72.08 Tahu
32 Apakah saudara setuju bahwa penyakit malaria bisa disembuhkan ? 2 6 37 168 26 927 77.25 Setuju

I Imunisasi

33 Apakah saudara mengetahui manfaat imunisasi ? 2 10 11 188 29 952 79.33 Tahu

34 Apakah saudara mengetahui jenis-jenis imunisasi ? 2 26 25 173 12 881 73.42 Tahu

J Diare

35 Apakah saudara setuju tanda-tanda penyakit diare antara lain berak lebih dari 3x sehari ? 2 3 20 190 24 948 79.00 Setuju
Apakah saudara mengetahui bahwa pencegahan penyakit diare dengan diberikan oralit dan
36 1 8 21 168 42 962 80.17 Sangat tahu
larutan gula garam (LGG) ?

K ISPA
37 Apakah saudara mengetahui tentang tanda-tanda penyakit ISPA ? 3 66 52 112 4 759 63.25 Tahu
38 Apakah menurut saudara penyakut ISPA berbahaya ? 1 20 77 129 14 858 71.50 Berbahaya

L POSBINDU

39 Apakah saudara mengetahui tentang adanya program posbindu ? 3 50 25 154 7 829 69.08 Tahu
40 Apakah saudara mengetahui jenis kegiatan yang dilakukan di Posbindu ? 3 58 34 139 5 802 66.83 Tahu
M KUSTA
41 Apakah saudara mengetahui penyakit kusta ? 6 84 33 115 3 748 62.33 Tahu
42 Apakah saudara setuju penyakit kusta dapat di obati ? 2 7 67 154 9 878 73.17 Setuju
N JIWA
43 Apakah saudara setuju bahwa penyakit jiwa itu keturunan? 4 69 43 117 6 769 64.08 Setuju
44 Apakah menurut saudara setuju penyakit jiwa dapat disembuhkan dengan obat ? 1 37 72 121 8 815 67.92 Setuju
45 Apakah saudara setuju penyakit jiwa pengobatannya dengan dipasung ? 46 113 10 55 22 632 52.67 Ragu-ragu

O LANSIA
 INDEKS %
NO DT DT SURVEY STS TS N S SS T. SKOR KESIMPULAN
(TS/Yx100)
46 Apakah saudara mengetahui tentang posyandu lansia ? 4 57 19 154 3 806 67.17 Tahu
47 Apakah saudara mengetahui kegiatan apa saja kegiatan di posyandu lansia ? 5 88 24 118 2 735 61.25 Tahu
48 Apakah saudara mengetahui manfaat pelayanan posyandu lansia ? 3 65 27 139 5 795 66.25 Tahu

P INDERA

49 Apakah saudara mengetahui tentang penyakit katarak ? 1 26 12 196 4 893 74.42 Tahu
50 Apakah saudara tahu tanda-tanda penyakit katarak ? 1 64 23 149 2 804 67.00 Tahu
51 Apakah saudara tahu bahwa penyakit katarak bisa disembuhkan ? 1 24 34 175 5 876 73.00 Tahu

Q PERKESMAS

52 Apakah saudara mengetahui tentang perawatan kesehatan masyarakat (Perkesmas) ? 4 22 28 175 9 877 73.08 Tahu
Apakah menurut saudara perlu dilakukan kunjungan rumah jika terdapat masalah kesehatan
53 1 8 12 174 43 964 80.33 Sangat perlu
di masyarakat (Perkesmas) ?

R HATTRA

54 Apakah saudara mengetahui tentang penyehatan/pengobatan tradisional ? 2 44 65 118 8 797 66.42 Tahu
55 Apakah saudara mengetahui jenis-jenis penyehatan/pengobatan tradisional ? 2 70 49 109 6 755 62.92 Tahu

Kriteria interpretasi skornya berdasarkan interval :

§  Angka 0% – 19,99% = Sangat (tidak setuju/buruk/kurang sekali)
§  Angka 20% – 39,99% = Tidak setuju / Kurang baik)
§  Angka 40% – 59,99% = Cukup / Netral
§  Angka 60% – 79,99% = (Setuju/Baik/suka)
§  Angka 80% – 100% = Sangat (setuju/Baik/Suka)