NAMA

No
NO RW RT PENDA NAMA KK ∑ JIWA
URUT
TA

1 2 1 1 muhtarudin 3
2 2 dadang 4
3 3 dadang gunawan 2
4 4 pahrudin 4
5 5 didi supriyadi 4
6 6 upah 4
7 7 syamsudin 3
8 8 encep 4
9 9 ma'mun 4
10 10 engkos kosasih 4
11 11 ugan 5
12 12 oma 7
13 13 aip syarif 5
14 14 saepul hidayat 7
15 15 indra 4
16 16 misdi 4
17 17 omi 5
18 18 andri 1
19 19 syamsu nazar 3
20 20 maman 4
21 21 dede 4
22 22 mahmur 4
23 23 mahmud 3
24 24 dedi gunawan 5
25 25 entong 5
26 26 idris 2
27 27 adang 4
28 28 ayip 2
29 29 deden 2
30 30 jepri 3
31 31 asirah 4
32 32 supardi 3
33 33 jaja 2
34 34 rumsah 5
35 35 nemah 4
36 36 Eko 4
37 37 Tobing 3
38 38 Yayat 4
39 39 Suryana 4
40 40 Siti Latifah 2
41 41 Mardios 2
42 42 Odih 3
43 43 Maksum 1
44 44 Suganda 4
45 45 mahpudin 3
46 46 agus 4
47 47 hasan 4
48 48 hasan ahmad tajudin 4
49 49 mansur 5
50 50 tajul islami 4
51 51 mukri 4
52 52 hamid arip 4
53 53 idrus 6
54 54 oji 4
55 55 aah 2
56 56 muksin 1
57 57 entim 3
58 58 ACE 2
59 59 KENEG 7
60 60 EUIS SAADAH 2
61 61 HASAN 3
62 62 UUN 4
63 63 YAYAN 5
64 64 UKAR BIN SANA 4
65 65 USEP 5
66 66 YUNUS 3
67 67 SAEPUDIN NURARIFIN 3
68 68 UDIN 3
69 69 NANANG MULYANA 3
70 70 USMAN HUSEN 3
71 71 USMAN JALALUDIN 3
72 72 SAEPULLOH 3
73 73 nur mista 6
74 74 saepudin 7
75 75 oleh 4
76 76 doni hamzani 3
77 77 pardi rahman 3
78 78 parid 5
79 79 apud 5
80 80 idrus 4
81 81 298
 UMUR JENIS KELAMIN AGAMA

12 -
0 - 11 1 - 4 5 - 11 26-45 46-65 > 65 LAKI- PEREM KRISTE
25 ISLAM
Bln tahun tahun tahun tahun tahun LAKI PUAN N
tahun

1 0 0 0 2 0 0 1 2 3 0
0 1 1 0 2 0 0 2 2 4 0
0 0 0 0 2 0 0 1 1 2 0
0 1 1 2 0 0 0 2 2 4 0
0 0 1 1 2 0 0 2 2 4 0
0 1 1 0 2 0 0 3 1 4 0
0 1 0 0 2 0 0 1 2 3 0
0 1 0 1 0 2 0 2 2 4 0
1 0 1 0 2 0 0 1 3 4 0
0 0 1 1 2 0 0 2 2 4 0
0 1 0 2 2 0 0 3 2 5 0
0 0 1 3 1 2 0 4 3 7 0
1 0 2 2 0 0 0 3 2 5 0
0 0 0 5 0 2 0 6 1 7 0
0 1 1 0 2 0 0 2 2 4 0
0 1 1 0 2 0 0 3 1 4 0
0 0 1 2 2 0 0 4 1 5 0
0 0 0 0 0 1 0 0 1 1 0
0 0 1 0 2 0 0 1 2 3 0
0 0 2 2 0 0 0 1 3 4 0
0 0 2 2 0 0 0 2 2 4 0
0 1 1 0 2 0 0 2 2 4 0
0 0 1 2 0 0 0 2 1 3 0
0 1 2 0 2 0 0 2 3 5 0
0 0 0 1 2 2 0 2 3 5 0
0 0 0 0 0 2 0 1 1 2 0
0 1 0 1 2 0 0 2 2 4 0
0 0 0 0 0 0 2 1 1 2 0
0 0 0 2 0 0 0 1 1 2 0
0 0 1 0 2 0 0 2 1 3 0
0 1 1 0 2 0 0 2 2 4 0
1 0 0 0 2 0 0 1 2 3 0
0 0 0 0 0 2 0 1 1 2 0
0 0 1 1 3 0 0 3 2 5 0
0 0 1 1 2 0 0 1 3 4 0
0 0 1 2 0 1 0 2 2 4 0
0 0 1 0 2 0 0 1 2 3 0
0 1 0 1 1 1 0 3 1 4 0
0 0 0 1 3 0 0 3 1 4 0
0 0 0 2 0 0 0 1 1 2 0
0 1 0 0 1 0 0 0 2 2 0
0 0 1 1 1 0 0 2 1 3 0
0 0 0 0 0 1 0 1 0 1 0
0 0 1 1 2 0 0 2 2 4 0
0 1 0 2 0 0 0 2 1 3 0
0 0 0 2 1 1 0 2 2 4 0
1 0 1 0 2 0 0 3 1 4 0
0 0 1 1 2 0 0 2 2 4 0
0 0 2 1 1 1 0 3 2 5 0
0 0 1 1 1 0 1 2 2 4 0
1 0 1 1 1 0 0 2 2 4 0
0 1 1 0 2 0 0 2 2 4 0
0 0 1 2 2 1 0 2 4 6 0
0 1 1 1 1 0 0 3 1 4 0
0 0 0 0 0 1 1 1 1 2 0
0 0 0 0 0 1 0 0 1 1 0
0 0 1 1 1 0 0 1 2 3 0
0 0 0 1 0 1 0 0 2 2 0
0 0 1 3 1 2 0 4 3 7 0
0 0 0 0 0 2 0 1 1 2 0
0 0 0 2 1 0 0 1 2 3 0
0 0 1 1 2 0 0 2 2 4 0
0 0 0 3 0 1 1 1 4 5 0
0 1 0 1 2 0 0 2 2 4 0
1 0 0 2 1 1 0 3 2 5 0
0 0 0 1 1 1 0 1 2 3 0
0 1 0 2 0 0 0 2 1 3 0
0 1 0 1 1 0 0 2 1 3 0
0 0 0 1 0 0 2 2 1 3 0
0 0 1 0 2 0 0 1 2 3 0
0 1 0 2 0 0 0 1 2 3 0
0 0 1 0 2 0 0 1 2 3 0
0 1 2 1 2 0 0 2 4 6 0
0 1 2 2 2 0 0 3 4 7 0
1 0 1 1 1 0 0 2 2 4 0
0 0 0 1 0 2 0 2 1 3 0
0 1 0 2 0 0 0 1 2 3 0
0 0 1 2 2 0 0 4 1 5 0
0 0 0 1 2 1 1 3 2 5 0
1 0 1 1 1 0 0 2 2 4 0
9 24 50 82 93 32 8 152 146 298 0
 AGAMA HUBUNGAN KELUARGA

KEPA KAK
ANAK ANA
KATHO KONGH LA ISTRI/ EK/
HINDU BUDHA AKNDU K CUCU
LIK UCHU KELU SUAMI NENE
NG TIRI
ARGA K

0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 5 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 5 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 0 0 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 1 2 0 0 1
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 0 3 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 0 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 0 0 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 4 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 0 0 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 0 1 0 0 0
0 0 0 0 1 1 5 0 0 0
0 0 0 0 1 1 0 0 0 0
0 0 0 0 1 0 2 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 1 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 4 0 0 0
0 0 0 0 1 1 5 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 1 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 3 0 0 0
0 0 0 0 1 1 2 0 0 0
0 0 0 0 80 73 142 1 0 1
GAN KELUARGA PENDIDIKAN

SAUD
BELUM BELUM TIDAK
PAMA ARA MENA MERT PEMB TAMAT TAMAT
SEKOL TAMAT TAMAT
N/BIBI KAND NTU UA ANTU SD SLTP
AH SD SD
UNG

0 0 0 0 0 1 0 0 0 1
0 0 0 0 0 1 0 0 2 1
0 0 0 0 0 0 0 0 2 0
0 0 0 0 0 0 1 0 2 0
0 0 0 0 0 0 1 0 2 0
0 0 0 0 0 1 1 0 1 0
0 0 0 0 0 0 1 2 0 0
0 0 0 0 0 0 1 0 2 1
0 0 0 0 0 1 1 2 0 0
0 0 0 0 0 0 2 0 2 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 0 1 6 0 0
0 0 0 0 0 0 2 0 2 0
0 0 0 0 0 0 1 0 6 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 1 0 2 1 0
0 0 0 0 0 1 0 0 3 1
0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 0 2 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 0 2 0 2 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 1 0 0 0 2
0 0 0 0 0 0 2 0 1 1
0 0 0 0 0 0 0 0 5 0
0 0 0 0 0 0 0 0 2 0
0 0 0 0 0 1 1 0 1 1
0 0 0 0 0 0 0 2 0 0
0 0 0 0 0 0 0 0 1 1
0 0 0 0 0 1 0 1 1 0
0 0 0 0 0 1 1 0 1 1
0 0 0 0 0 1 0 0 0 1
0 0 0 0 0 0 0 0 2 0
0 0 0 0 0 1 0 0 4 0
0 0 0 0 0 0 1 0 0 3
0 0 0 0 0 0 1 0 3 0
0 0 0 0 0 0 1 0 1 1
0 0 0 0 0 1 0 0 2 1
0 0 0 0 0 0 0 0 2 1
0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 1 0 0 1 0
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 0 1 0 2 1
0 0 0 0 0 1 0 0 1 1
0 0 0 0 0 0 1 0 3 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 1 0 0 1 2
0 0 0 0 0 1 1 0 0 2
0 0 0 0 0 1 0 0 3 0
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 1 1 0 1 1
0 0 0 0 0 1 1 0 2 2
0 0 0 0 0 2 0 0 2 0
0 0 0 0 0 1 0 0 1 0
0 0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 1 0 2 0
0 0 0 0 0 0 0 0 2 0
0 0 0 0 0 1 1 0 4 1
0 0 0 0 0 2 0 0 0 0
0 0 0 0 0 0 2 0 1 0
0 0 0 0 0 1 0 0 1 2
0 0 0 0 0 0 1 0 3 1
0 0 0 0 0 2 0 0 2 0
0 0 0 0 0 1 0 0 4 0
0 0 0 0 0 0 0 0 1 0
0 0 0 0 0 1 0 0 2 0
0 0 0 0 0 1 0 1 1 0
0 0 0 0 0 0 0 2 1 0
0 0 0 0 0 1 0 0 2 0
0 0 0 0 0 1 0 0 1 1
0 0 0 0 0 1 0 0 2 0
0 0 0 0 0 0 0 0 5 1
0 0 0 0 0 0 0 2 2 1
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 0 0 0 2 1
0 0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 1 0 4 0
0 0 0 0 0 0 0 0 4 1
0 0 0 0 0 1 1 0 2 0
0 0 0 0 0 45 42 21 137 37
PENDIDIKAN

MENGU
BELUM/ PELAJA
RUS
TIDAK R/
SLTA DI/II DIII DIV/SI SII SIII RUMAH
BEKERJ MAHAS
TANGG
A ISWA
A

1 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0
1 0 0 0 0 0 1 1 0
1 0 0 0 0 0 0 1 2
1 0 0 0 0 0 0 1 1
0 0 0 0 0 0 0 1 2
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 2
1 0 0 0 0 0 0 1 2
0 0 0 0 0 0 3 1 0
1 0 0 0 0 0 0 1 2
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 2 1 1
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 2
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1 0
1 0 0 0 0 0 1 1 2
0 0 0 0 0 0 0 2 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 1 1
1 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 1 2
0 0 0 0 0 0 0 1 1
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 2 1 0
1 0 0 0 0 0 2 1 0
1 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 1 0
1 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 0
0 0 0 0 0 2 1 0
0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 1 0 1
1 0 0 0 0 0 1 1 1
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 2 1 2
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 4 0 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 2
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 0 1 2
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 1 1 2
2 0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 0 1 4
2 0 0 0 0 0 0 1 4
0 0 0 0 0 0 1 1 1
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 1 1 0
0 0 0 0 0 0 2 1 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 0 2 1 0
16 0 0 0 0 0 62 73 51
 PEKERJAAN

PERDA
PENSIU PETERN INDSUT KONST
PNS TNI POLRI GANGA PETANI
NAN AK RI RUKSI
N

0 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
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 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 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 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 1 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 1
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 1 0 0 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 0 0 0
0 0 0 0 0 0 0 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 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 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 1 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 1 0 0 0 0
0 0 0 0 0 2 0 0 0
0 0 0 0 0 0 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 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 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 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 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 0 0 0 0
0 0 0 0 0 0 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 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 16 6 1 0 4
N

KARY KARY. BURUH

TRANSP KARY. KARY. BURUH PEMBA
SWAST HONOR BURUH TERNA
ORTASI BUMN BUMD TANI NTU RT
A ER K

0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 1 0 0 0 1 0 0 0
0 1 0 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 1 0 0 0 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
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 1 0 0 0 3 0 0 0
0 1 0 0 0 0 0 0 0
0 0 0 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 0 0 0 1 0 0 0
0 1 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 1 0 0 0 2 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 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 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 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 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 1 0 0 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 0 0 1 0 0 0
0 0 0 0 0 0 0 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 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 2 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 1 1 0 0 0
0 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 1 0 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 0 0 0
1 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 2 0 0 0
0 1 0 0 0 3 0 0 0
0 0 0 0 0 1 0 0 0
2 22 1 0 1 45 1 0 0
 kesehatan keluarga 6 bulan tera

RIWAY KANKE
AT TB R DM
TB TB DM
PNEUM (TUNTA (keternga TIDAK
GINJAL PENGO PUTUS ASMA TERKO
ONIA S n kanker TERKO
BATAN OBAT NTROL
PENGO apa NTROL
BATAN) ditulis)

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 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 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 0 0
0 0 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 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 1 0 0 0 0 1 0 0
esehatan keluarga 6 bulan terakhir

HT ODGJ
HT ODGJ
TIDAK JANTU STROK TIDAK HEPATI
TERKO TRKON KUSTA HIV
TERKO NG E TERKO TIS
NTROL TROL
NTROL NTROL

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 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 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 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 0 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 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 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 0 0 0 0 0 0 0 0
0 0 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
1 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 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 0 0 0 0 0 0 0 0
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 TEMPAT PELAYANAN

Keterang
an
( UNTU Pustu/
RS Poskesde
K RSUP/ RS Puskesm Prakter Pusling/
POLRI/T Klinik s/
PENYA RSUD Swasta as Dokter Bidan
NI Polindes
KIT Desa
LAINNY
A)
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
magh 0 0 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
lambung, lambung 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
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0 0 0 0 0 0 0 0 0
gondong 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
lqmbung 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
magh 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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2 0 0 0 0 0 0 0 0
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0 0 0 0 0 1 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 1 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 2 0 0 0
0 0 0 0 0 0 0 0 0
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 PENGAMBIL KEPUTUSAN KEMATIN DALAM 1 TAHUN TERAKHIR

BULAN/
SEBAB
Praktek SUA SUAMII TAHUN
Lainnya ISTRI LAIN2 NAMA SEX KEMAT
Bidan MI STRI KEMAT
IAN
IAN

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0 0 0 1 0 0 0 0 0 0
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0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
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0 tidak berobat 0 0 1 0 0 0 0 0
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0 0 0 0 0 0 0 0 0 0
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0 0 0 1 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
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0 0 1 0 0 0 0 0 0 0
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0 0 0 0 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
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HUN TERAKHIR IBU HAMIL USIA KEHAMILAN ANC

LENGK
DIAGNOS
KET HPHT TP TM I TM II TM III AP (> 4
A
KALI)

0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 13-04-2018 20-01-2019 G2P1A0 0 0 33 mg 0
0 0 0 0 0 0 0 0
0 15-07-2018 1/5/2019 G3P2A0 0 0 21 mg 0
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0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 5/18/2018 2/25/2019 G2P1A0 0 1 0 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 6/15/2018 4/27/2019 G5P4A0 0 1 0 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 8/18/2018 5/24/2019 G2P1A0 0 1 0 1
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
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 Ibu hamil

ANC PERIKSA HAMIL Bila tidak ANC alasanya

DOKTE
TIDAK Jarak
RS/ R/
LENGK POLIND POSYAND pelayanan
PUSKES BIDAN Tidak tahu Tidak mau
AP (< 4 ES U kesehatan
MAS PRAKT
KALI) jauh
EK

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0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
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1 0 0 0 0 0 0 1
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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C alasanya IMUNISASI TT Alasan tidak imunisasi

TIDAK TIDAK
Lain-lain LENGK YanKes Tahu tapi Lain-lain
LENGK IMUNISA Tidak tahu
(Sebutkan) AP Jauh tidak mau (sebutkan)
AP SI

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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 3 0 2 1 0 1 0
 NEONATUS (0-28
RENCANA HARI
GIZI IBU HAMIL Alasan tidak periksa sama sekali
PERSALINAN

TIDAK TIDAK Tahu tapi

ANEMI NON LENGK Tidak YanKes
ANEMI NAKES LENGK tidak
A NAKES AP tahu Jauh
A AP mau

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0 0 0 0 0 0 0 0 0
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 Ibu Ni

iksa sama sekali NIFAS Tempat pemeriksaan Alasan tidak periksa sam

Lain-lain
Bidan
(sebutkan YA TIDAK RS PUSKESMAS POLINDES Tidak tahu
Praktek
)

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0 0 0 0 0 0 0 0
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 Ibu Nifas. (Ibu 40 Hari)
melakukan
Apakah ibu Obat-obatan yang
Alasan tidak periksa sama sekali perawatan
menyusui diminum saat ini
puerperium

YanKes Tahu tapi Lain-lain TIDA

YA TIDAK Vit.A Fe YA
Jauh tidak mau (sebutkan) K

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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 0 0 0 1
 Ibu Bersalin : (umur anak terakhir 0-1 tahun
CARA melakukan
Tempat
perawatan Jika tidak, alasan menolong persalinan
bersalin
puerperium

Tahu tapi Petugas Dukun Lain-lain Sarana

Tidak Dukun
Benar Salah tidak Kesehata Tidak (sebutkan Kesehata
tahu terlatih
mau n terlatih ) n

0 0 0 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 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 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 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 5 2 1 0 5
hir 0-1 tahun menyusui (umur anak terakhir 0 - 1 tahun)

melakukan
menyusui bayinya Kadar haemoglobin
perawatan payudara

1,1 - 2 6,1 bulan < 12 12-14 gr > 14

Rumah 0-6 bulan > 2 tahun YA
tahun - 1 tahun gr/% % gr/%

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 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 0 0 0 0 0 0
0 0 0 0 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 0 0 0 0 0 0
1 0 1 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 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 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 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 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 0
3 0 7 0 0 0 0 0 0
khir 0 - 1 tahun) Sistem Reproduksi Ibu

melakukan CARA melakukan

Jika tidak, alasan PMS/STD
perawatan payudara perawatan payudara

Rasa
Tahu tapi Masalah Keluhan
Tidak Keputiha gatal
TIDAK Benar Salah tidak hubunga buang air
tahu n pada
mau n sexsual kecil
kemaluan

1 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0
0 0 0 0 0 1 0 1 0
1 0 0 1 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0
0 0 0 0 0 1 0 1 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 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 1 0 1 0 1 0
9 0 0 9 0 11 1 8 0
 Sistem
Reprodu
ksi
istem Reproduksi Ibu
Remaja
(12 – 20
Apakah sudah Menopau tahun) Apakah sudah
Kelainan genital
berobat se berobat

Rasa
Masalah Keluhan
Keputiha gatal
YA TIDAK YA TIDAK pertumbu buang air YA
n pada
han kecil
kemaluan

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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0 0 0 0 0 0 0 0 0
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1 0 0 1 0 0 0 0 0
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0 0 0 1 0 0 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 1 0 1 1 1 0 0 1
0 1 0 1 0 0 0 0 0
0 1 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 1 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
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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
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0 0 0 1 0 0 0 0 0
0 0 1 0 1 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 1 0 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 1 0 1 0 0 0 0 0
1 0 0 1 0 0 0 0 0
1 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 0 1 0 0 0 0 0
0 0 1 0 0 0 0 0 0
0 1 0 0 0 0 0 0 0
5 9 15 27 2 2 0 0 1
 Keluarga Berencana (U

Apakah sudah Menstrua keluarga

KB ME
berobat si PUS

TIDAK YA BELUM YA TIDAK YA TIDAK IUD MOW

0 0 0 1 0 1 0 0 0
0 1 0 1 0 1 0 0 0
0 0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 1 0 0 0
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0 1 0 1 0 1 0 0 0
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0 0 0 0 1 0 1 0 0
0 1 0 1 0 0 1 0 0
0 1 0 0 1 0 1 0 0
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0 1 0 1 0 1 0 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 1 0 1 0 1 0 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 1 0 0 0
0 1 0 1 0 1 0 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 0 1 0 0
0 0 0 0 1 0 1 0 0
0 0 0 1 0 0 1 0 0
0 1 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0 0
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0 0 0 1 0 1 0 0 0
1 1 0 0 1 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 1 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 1 0 0 0
0 0 0 0 1 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 0 0 1 0 0 1 0 0
0 0 1 1 0 1 0 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 1 0 0 0
0 0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0 0
0 1 0 0 1 1 0 0 0
0 0 0 0 1 0 1 0 0
0 0 0 1 0 1 0 0 0
2 19 1 57 12 43 29 0 0
Keluarga Berencana (Usia ibu < 45 th dan mempunyai pasangan)

lama memakai alat

METODE Tempat pelayanan KB
kontrasepsi

KONDO TRADIS <5 >5 Bidan/

MOP IMPLAN SUNTIK PIL RB
M IONAL TAHUN TAHUN dokter

0 0 1 0 0 0 1 0 1 0
0 0 0 1 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 1 0 1 0
0 0 1 0 0 0 0 1 1 0
0 0 1 0 0 0 1 0 1 0
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0 0 0 0 0 0 0 0 0 0
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0 0 1 0 0 0 1 0 1 0
0 0 1 0 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 1 1 0
0 0 0 1 0 0 1 0 1 0
0 0 0 1 0 0 1 0 1 0
0 0 0 1 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 0 0 0 0
0 0 0 1 0 0 0 1 1 0
0 0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 1 0 1 0
0 0 0 1 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 1 0
0 0 1 0 0 0 1 0 1 0
0 0 0 1 0 0 0 1 1 0
0 0 1 0 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 0 1 1 0
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0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 1 0
0 0 1 0 0 0 1 0 1 0
0 0 0 0 0 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
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0 0 0 1 0 0 1 0 1 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 1 0
0 0 1 0 0 0 0 1 1 0
0 0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 1 0
0 0 28 16 0 0 33 6 38 0
 DATA KESEHATAN BAYI

Tempat
Tempat pelayanan KB Apakah bayi sering ditimbang Alasan tidak periksa sama
penimbangan :

Puskesm
Teratur
as /
( 12 x/ Tidak Tidak
RS Puskesmas Ya Tidak Posyandu Fasilitas
sesuai teratur tahu
kesehata
usia)
n lain

0 0 1 0 1 0 1 0 0
0 warung 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 warung 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 0
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0 0 0 0 0 0 0 0 0
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0 0 1 0 1 0 1 0 0
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0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 0 1 0 0
0 1 6 2 7 1 8 0 0
AYI Status imunisasi

Alasan tidak periksa sama sekali BCG HB DPT

Tahu tapi Lain-lain

YanKes tidak tidak tidak
tidak (sebutkan Lengkap Lengkap Lengkap
Jauh Lengkap Lengkap Lengkap
mau )

0 0 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
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0 0 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 HB 1, 2 0 0 1
0 1 0 8 0 7 0 5 2
 Status imunisasi

Bila tidak Lengkap atau tidak imunisasi,

POLIO CAMPAK mempunyai KMS
alasan

Tahu, Tahu tapi

tidak tidak Tidak Yankes
Lengkap Lengkap tapi Ibu Tidak Ya
Lengkap Lengkap tahu jauh
sibuk mau

1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 0 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
0 1 0 1 0 0 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 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
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 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
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
POLIO 1, 2 1 0 0 0 0 0 1 1
6 2 2 1 0 0 1 2 9
mempunyai KMS KMS terisi

Tidak Ya Tidak

0 1 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
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 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 1 0
0 0 0
0 0 0
0 0 0
0 1 0
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 0
0 0 0
0 0 0
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 0
0 0 0
0 0 0
0 0 0
0 1 0
0 0 0
0 0 0
0 0 0
0 0 0
1 0
0 9 0
 Makanan
Status pemberian
ASI

NAMA
No
NO RW RT PENDA NAMA KK ∑ JIWA
URUT Masih
TA
diberikan

64 2 1 1 muhtarudin 4 0
65 2 dadang 2 0
66 3 dadang gunawan 4 0
67 4 pahrudin 4 0
68 5 didi supriyadi 4 0
69 2 1 6 upah 3 0
70 7 syamsudin 4 0
71 8 encep 4 1
72 9 ma'mun 4 0
73 10 engkos kosasih 5 0
74 11 ugan 7 0
75 12 oma 5 0
76 13 aip syarif 7 0
77 14 saepul hidayat 4 0
78 15 indra 4 0
79 16 misdi 5 0
80 17 omi 1 0
81 18 andri 3 0
82 19 syamsul nazar 4 0
83 20 maman 4 0
84 21 dede 4 0
85 22 mahmur 3 0
86 23 mahmud 5 0
87 24 dedi gunawan 5 0
88 25 entong 2 0
89 26 idris 4 0
90 27 adang 0 0
91 28 ayip 2 0
92 29 deden 3 0
93 30 jepri 4 0
94 31 asirah 1 0
95 32 supardi 2 0
96 33 jaja 6 0
97 34 rumsah 1 0
98 35 nemah 4 0
99 36 Eko 3 0
100 37 Tobing 4 0
101 38 Yayat 4 0
102 39 Suryana 2 0
103 40 Siti Latifah 2 0
104 41 Mardios 3 0
105 42 Odih 1 0
106 43 Maksum 4 0
107 44 Suganda 3 0
108 45 mahpudin 4 0
109 46 agus 4 1
110 47 hasan 4 0
111 48 hasan ahmad tajudin 5 0
112 49 mansur 4 0
113 50 tajul islami 4 1
114 51 mukri 4 0
115 52 hamid arip 6 0
116 53 idrus 4 1
117 54 oji 2 0
118 55 aah 1 0
119 56 muksin 3 0
120 57 entim 2 0
121 58 ACE 7 0
122 59 KENENG 2 0
123 60 EUIS SAADAH 0 0
124 61 HASAN 4 0
125 62 UUN 3 0
126 63 YAYAN 4 0
127 64 UKAR BIN SANA 5 1
128 65 USEP 3 0
129 66 YUNUS 3 0
130 67 SAEPUDIN NURARIFIN 2 0
131 68 UDIN 0 0
132 69 NANANG MULYANA 3 0
133 70 USMAN HUSEN 3 0
134 71 USMAN JALALUDIN 3 0
135 72 SAEPULLOH 6 0
136 73 nur mista arpin 7 0
137 74 saepudin 4 1
138 75 oleh 3 0
139 76 doni 3 0
140 77 pardi rahman 5 0
141 78 parid 4 0
142 79 apud 5 0
143 80 idrus 4 1
144
145
146
147
148
149
150
151
152
153
 Makanan Yang Diberikan kepada bayi
Status pemberian
Jika tidak, alasan MPASI Jika tidak sesuai, alasan
ASI

Ibu
Tahu, Tahu tapi ASI
Tidak Tidak Menderit Tidak Tidak
tapi ibu Tidak Sedikit/ sesuai
diberikan tahu a suatu sesuai tahu
sibuk mau Terhenti
penyakit

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 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 0 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 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 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 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 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 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 1 0 0
Jika tidak sesuai, alasan Status Gizi Pemberian Pasi Apakah bayi sering ditimbang

Lain-
Kebiasaa
lain, Sebelum Setelah 6
n/Tradisi Baik Cukup Kurang Ya Tidak
(sebutka 6 bulan bulan
setempst
n)

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 1 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
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 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0
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 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 0 0 0 0 0
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 0
0 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
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 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 0 0 0 0 0 0 1 0
0 0 0 0 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 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 0
0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
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 0
0 0 0 0 0 0 0 0 1
0 0 1 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
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 0
0 0 0 0 0 0 0 0 0
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 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 0 0 0 0 0
0 0 1 0 0 0 1 0 0
 Tempat
kah bayi sering ditimbang Alasan tidak periksa sama sekali BCG
penimbangan :

Puskesm
Teratur
as / Tahu tapi Lain-lain
( 12 x/ Tidak Posyand Tidak YanKes
Fasilitas tidak (sebutkan Lengkap
sesuai teratur u tahu Jauh
kesehata mau )
usia)
n lain

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
0 0 0 0 0 0 0 0 0
0 1 1 0 0 1 0 0 1
0 1 1 0 0 1 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 1 1 0 1 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 0 0 1 0
0 0 0 0 0 0 0 0 0
0 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 1
0 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 1
1 0 1 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 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 1 0 0 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 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 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 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 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 DATA KESEHATAN BALITA
BCG HB DPT POLIO CAMPAK

tidak tidak tidak tidak tidak

Lengkap Lengkap Lengkap Lengkap
Lengkap Lengkap Lengkap Lengkap Lengkap

0 1 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 1 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 HB 1 0 DPT 1 0 Polio 1 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 1 0 1 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
1 0 1 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 1 0 1 0 1 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
Bila tidak Lengkap atau tidak imunisasi,
mempunyai KMS KMS terisi Status Gizi
alasan

Tahu, Tahu tapi

Tidak Yankes
tapi Ibu Tidak Ya Tidak Ya Tidak Baik
tahu jauh
sibuk mau

0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 1 0 1 0 1
0 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
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 1 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
1 0 0 0 0 1 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 0 0 0 0 0
0 1 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 1 0 1 0 1 0 1
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 1 0 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 1 0 1 0 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 1 0 0 0 1 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 1 0 1 0 1 1
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 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
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
Status Gizi Ventilasi JENIS LANTAI

Cukup Kurang Baik Cukup Kurang Tanah Ubin Semen Papan

0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 0 1 0
0 0 1 0 0 0 0 1 0
0 0 0 1 0 0 1 0 0
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 1 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 0 1 0
0 0 1 0 0 0 1 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 1 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 0 1 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 0 1 1
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 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 1 0
0 0 0 1 0 1 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 1 0 0 0 0 1 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 0 1 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 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 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 1 0
0 0 0 1 0 0 0 1 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 0 1 0
0 0 0 0 1 0 1 0 0
0 0 0 1 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 1 0 0 0 1 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 0 1 0
0 0 1 0 0 0 0 1 0
0 0 0 1 0 0 0 1 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 0 1 0
0 0 0 1 0 0 0 1 0
0 0 1 0 0 0 1 0 0
0 0 0 1 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 1 0
0 0 1 0 0 0 1 0 0
0 0 1 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 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 1 0 0 0 1 0 0
0 0 0 1 0 0 1 0 0
0 0 0 1 0 0 1 0 0
 DATA LINGKUNGAN
SPAL (Sistim Pembuangan
Sumber air bersih Kondisi air
Air Limbah)

Memenu Tidak
Sumur/ hi syarat memenu Selokan/
Mata air Sungai PAM Lain-lain Empang
Pompa kesehata hi syarat Got
n Kes

0 0 1 0 0 0 1 1 0
1 0 0 0 0 1 0 1 0
1 0 0 0 0 1 0 1 0
0 0 1 0 0 0 1 0 0
1 0 0 0 0 1 0 1 0
0 1 0 0 0 1 0 1 0
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1 0 0 0 0 1 0 1 0
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1 0 0 0 0 1 0 1 0
0 1 0 0 0 1 0 1 0
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1 0 0 0 0 0 1 1 0
0 0 1 0 0 0 1 0 1
1 0 0 0 0 1 0 1 0
0 1 0 0 0 1 0 1 0
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Pembuangan Tinja Kandang BPJS
Air Limbah)

Sembara
Sembara Septik Cemplun Sungai/ Memiliki
Cubluk ng ada tidak
ngan tank g seloka
tempat

0 1 0 0 0 0 1 0 1
0 0 0 0 1 0 1 0 2
0 0 0 0 1 0 1 0 0
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0 1 0 0 0 0 0 1 0
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1 0 0 0 1 0 1 0 0
0 1 0 0 0 0 0 1 0
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1 0 0 0 1 0 0 1 0
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0 0 0 0 1 0 0 1 0
0 0 0 0 1 0 1 0 0
0 0 0 0 1 0 0 0 4
0 0 0 0 1 0 0 1 0
0 0 0 0 1 0 0 1 0
0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 1 0
0 1 0 0 0 0 0 1 0
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1 1 0 0 0 0 0 1 1
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0 1 0 0 0 0 1 0 0
0 0 0 0 1 0 0 1 0
 FASILITAS/SARANA KESEHATAN
Fasilitas Kesehatan
Fasilitas Kesehatan yang
BPJS Jarak fasilitas masyarakat yang terdekat dari
terdekat dari rumah Keluarga
rumah Keluarga

Rumah Puskesm Klinik Posyand Poskesde

Tidak < 5 KM > 5 KM Polindes
sakit as swasta u s

0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
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1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
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1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
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1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
0 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
1 0 1 0 1 0 0 1 0
KESEHATAN
Jenis transportasi yang digunakan ke pelayanan
Jarak fasilitas
kesehatan

Angkuta
Ojek/ Lain-lain
n Jalan PNEUM
< 5 KM > 5 KM roda 2 Delman (sebutkan GINJAL
kota/roda kaki ONIA
)
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1 0 0 1 0 0 0 0 0
1 0 0 1 0 0 0 0 0
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1 0 0 1 0 0 0 0 0
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1 0 0 1 0 0 0 0 0
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1 0 0 1 0 0 0 0 0
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RIWAY KANKE
AT TB R DM HT
TB TB DM HT
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PENGO PUTUS ASMA TERKO TERKO
S n kanker TERKO TERKO
BATAN OBAT NTROL NTROL
PENGO apa NTROL NTROL
BATAN) ditulis)

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Keterang
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ODGJ ( UNTU
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JANTU STROK TIDAK HEPATI K
TRKON KUSTA HIV
NG E TERKO TIS PENYA
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NTROL KIT
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