MATERI KEGIATAN PKK

F O R M A T P E N ILA IA N LO M B A D ES A D A N K E LU R A H A N
PELA KSA N A TE R B A IK P O SYA N D U

PO SYAN D U : ................................................... / STRATA: ................................

D ESA /KELU R A H AN : ................................................... / JUMLAH POSYANDU: ..............
KECA M AT A N : ................................................... / JUMLAH POSYANDU: ..............
KA BU PAT EN /KO TA : ................................................... / JUMLAH POSYANDU: ..............
P R O V IN S I : ................................................... / JUMLAH POSYANDU: ..............

N a m a P e n ila i :
T a n g g a l P e n il a ia n :
T a n d a t a n g a n p e n ila i :

NO IN D IKA T O R NILAI N ILA I N ILA I SUMBER

R IIL BOBOT TERTIMBANG DATA
A IN D IK A TO R M AS UK A N
1 D u k u n g a n k e b ij a k a n p e n y e le n g g a r a a n B u k ti S K , S u r a t
p osy an d u E d a r a n , d ll
a . P r o v in s i, K a b u p a t e n / K o t a , 100 3
K e c a m a t a n , D e s a / K e lu r a h a n
b . K a b u p a t e n / K o ta , K e c a m a t a n , 75 3
D e s a / K e lu r a h a n
c. K e c a m a ta n , D e s a / K e lu ra h a n 50 3
d. D e s a / K e lu ra h a n 25 3
C a ta ta n :
2 A d a n y a P o k j a n a l, P o k ja P o s y a n d u d i B u k ti S K , S u r a t
tin g k a t : E d a r a n , d ll
a . P r o v in s i, K a b u p a t e n / K o t a , 100 3
K e c a m a t a n , D e s a / K e lu r a h a n
b. K a b u p aten /Ko ta, Ke ca m atan , 75 3
D e s a / K e lu r a h a n
c. K e c a m a t a n , D e s a / K e lu r a h a n 50 3
d. D e s a / K e lu r a h a n 25 3
C a ta ta n :
3 A n g g o t a T P P K K P r o v in s i, B u k ti S K , S u r a t
K a b u p a te n / K o ta , K e c a m a t a n y a n g a d a E d a r a n , d ll
d a la m k e p e n g u r u s a n P o k ja n a l
a . P r o v in s i, K a b u p a t e n / K o t a , 100 3
K e c a m a t a n , D e s a / K e lu r a h a n
b . K a b u p a t e n / K o ta , K e c a m a t a n , 75 3
D e s a / K e lu r a h a n
c. K e c a m a ta n , D e s a / K e lu ra h a n 50 3
d. D e s a / K e lu ra h a n 25 3
C a ta ta n :
4 D a l a m s a tu t a h u n y a n g l a lu , b e r a p a k a li B u k u Ba n tu
p o k j a n a l/ p o k j a p o s y a n d u m e n g a d a k a n C a ta ta n d i
p erte m u a n P o sy an d u
a. 3 k a li a t a u le b ih 100 3
b. 2 k a li 75 3
c. 1 k a li 50 3
d. T id a k a d a 25 3
C a ta ta n :
5 K e h a d ir a n u n s u r P o k j a P o s y a n d u s a a t B u k u Ba n tu
h a ri b u k a p e n im b a n g a n C a ta ta n d i
a. 8 k a li a ta u l e b ih 100 3 P o sy an d u
b. 6 - 7 k a li 75 3

Pedoman Kesatuan Gerak PKK-KKBPK-Kesehatan Lampiran

 c. 4 - 5 k a li 50 3
d. 1 - 3 k a li 25 3
C a ta ta n :
6 P e m b ia y a a n k e g ia t a n P o s y a n d u C a ta ta n d i
a. 5 s u m b e r a ta u l e b ih 100 3 P o sy an d u ,
b. 4 su m ber 75 3 Su m ber dan a:
c. 3 su m b er 50 3 1. D an a Seh at
d. 1-2 su m ber 25 3 2. Sw adaya
m a sy a ra k a t
3. D e sa/
K e lu ra h a n
4. Ke ca m atan
5 . K a b u p a te n /
K o ta
6 . S w a s ta /
d u n ia u s a h a
7 . L a in - la i n
C a ta ta n :
7 Jum la h d u k u n g a n D a n a D e s a / K e lu ra h a n u n tu k k e g ia ta n p e n y e le n g g a ra a n d i Po sya nd u
a. L e b ih d a r i 1 0 % ( R p . . .. . .. . . .. . .. . .. . ) 100 3 C a ta ta n d i T P
b. 5 -1 0 % (R p . ....................... ) 75 3 PKK
c. 1 - 4 % ( R p . ....................... ) 50 3 D e s a / K e lu r a h a n :
d. T id a k a d a 25 3 D ukung an
an g g a ra n u n tu k
k e g ia ta n
p e n y e le n g g a r a a n
P o sy an d u d i
d e s a /k e lu ra h a n
ya n g b e rs u m b er
d a r i:
1. D an a D esa
(A P B N )
2. AD D (AP BD )
3. K e lu ra h a n
C a ta ta n :
8 G e d u n g / te m p a t k e g ia t a n P o sy an d u m ilik : C a ta ta n T P P K K
a. 5 s u m b e r a ta u l e b ih 100 3 D e s a / K e lu r a h a n ,
b. 4 su m ber 75 3 Su m ber:
a. 3 su m ber 50 3 1. W a rg a/
d. 1-2 su m b er 25 3 p r ib a d i
m a sy a ra k a t
2 . H ib a h
3. B a n tu an
P e m e r in ta h
4. D e sa/
K e lu ra h a n
5 . S w a s ta /
D u n ia U s a h a
C a ta ta n :
9 S a ra n a p o sy a n d u C a ta ta n d i
a. 6 s a r a n a a t a u l e b ih 100 3 P o sy an d u
b. 5 saran a 75 3 J e n is S a r a n a :
c. 4 s a ra n a 50 3 1 . T im b a n g a n
d. 3 saran a 25 3 d a c in d a n k a in
2 . S IP
3 . A la t u k u r
tin g g i b a d a n
d a n lin g k a r
k e p a la /L IL A
4. Buk u KIA /
KM S
5 . M e d ia K IE
6 . B a lo k S K D N
 C a ta ta n :
10 D a ta a w a l s a s a r a n d id a p a t d a r i : 1. C a ta ta n
a. U p a y a k a d e r s e n d ir i s a a t k u n ju n g a n 100 3 K e lo m p o k
r u m a h , H a s il r e k a p i tu l a s i k e l o m p o k D a s a w is m a
D a s a w is m a , D a r i P u s k e s m a s 2. S IP
b . H a s il r e k a p i t u l a s i k e l o m p o k 75 3
D a s a w is m a , D a r i P u s k e s m a s
c . U p a y a k a d e r s e n d ir i s a a t k u n ju n g a n 50 3
ru m a h , D a ri P u sk es m a s
d . D a ri P u sk es m a s 25 3
C a ta ta n :

B IN D IK A TO R P R O S ES
1 A d a n y a P e l a tih a n C a ta ta n T P P K K
K a d e r P o s y a n d u d a la m s a tu ta h u n : D e s a / K e lu r a h a n
a . 4 k a li a t a u le b i h 100 4
b . 3 k a li 75 4
c . 2 k a li 50 4
d . 1 k a li 25 4
C a ta ta n :
2 J u m l a h k a d e r y a n g t e r la tih C a ta ta n T P P K K
a . 5 o r a n g a t a u le b i h 100 4 D e s a / K e lu r a h a n
b. 4 orang 75 4
c . 3 o ra n g 50 4
d. 1 -2 o ra n g 25 4
C a ta ta n :
3 J e n is p e l a tih a n y a n g te l a h d iik u ti k a d e r C a ta ta n T P P K K
P o sy an d u : D e s a / K e lu r a h a n .
a. 3 p e l a tih a n a t a u l e b ih 100 4 J e n is p e l a tih a n
b . 2 p e la tih a n 75 4 ( s e r tifik a t ) :
c . 1 p e l a tih a n 50 4 1 . M a n a je m e n
d. tid a k a d a 25 4 P o sy an d u
2 . p e la tia h a n
s y s te m
p e la p o r a n
P o sy an d u
3 . P e la tih a n
te k n is
P o sy an d u
( G iz i , K I A ,
P e n y u lu h a n ,
d ll )
C a ta ta n :
4 P e la tih a n d is e l e n g g a r a k a n o le h b e r b a g a i C a ta ta n T P P K K
p ih a k : D e s a / K e lu r a h a n
a. 5 p e n y e le n g g a r a a t a u l e b i h 100 4 P ih a k
b. 4 p e n y e le n g g a r a 75 4 p e n y e le n g g a r a
c. 3 p e n y e le n g g a ra 50 4 p e la tih a n :
d. 1 -2 p e n y e le n g g a ra 25 4 1. M a n a je m e n
P o sy an d u
2. S IP
3. P e la tih a n
te k n is
4. TP PKK
K a b u p a te n /
K o ta
5. S w a s ta / d u n i
a usaha
6. L a in - la i n
(LS M , N G O ,
d ll )
C a ta ta n :
5 P e m b in a a n P o s y a n d u o l e h : C a ta ta n T P P K K
a . 4 p e m b in a a ta u l e b ih 100 4 D e s a / K e lu r a h a n
b. 3 p e m b in a 75 4 P e m b in a :
c. 2 p e m b in a 50 4 1. P o k ja
d. 1 p e m b in a 25 4 P o sy an d u
2. TP PKK
D e sa/
K e lu ra h a n
3. P uske sm a s
4. S w a s ta /
D u n ia U s a h a
5. L a in - la i n
(LS M , N G O ,
d ll )
C a ta ta n :
6 F r e k u e n s i p e m b in a a n p o s y a n d u d a l a m
s a tu ta h u n :
a . 8 k a li a t a u le b i h 100 4
b . 6 - 7 k a li 75 4
c . 4 - 5 k a li 50 4
d . 1 - 3 k a li 25 4
C a ta ta n :
7 E v a lu a s i s e t e la h p e n i m b a n g a n o le h k a d e r C a ta ta n Kad er
d a n p e t u g a s d a la m s a tu t a h u n
a. A d a , 8 k a li a t a u l e b ih 100 4
b. A d a , 4 - 7 k a li 75 4
c. A d a , 1 - 3 k a li 50 4
d. T id a k a d a 25 4
C a ta ta n :
8 T in d a k l a n ju t p e n i m b a n g a n a d a C a ta ta n Kad er
k u n j u n g a n r u m a h d a la m s a tu b u la n
a. A d a , 4 k a li a t a u l e b i h 100 4
b. A d a , 3 k a li 75 4
c. A d a , 1 - 2 k a li 50 4
d. T id a k a d a 25 4
C a ta ta n :
9 B a g i y a n g tid a k m a u h a d ir k e P o s y a n d u , C a ta ta n Kad er
u p a y a y a n g d il a k u k a n a d a la h :
a . 4 u p a y a a ta u l e b ih 100 4 C a ta ta n B u k u
b. 3 upa ya 75 4 K e g ia ta n T P P K K
c. 2 upaya 50 4 D e s a / K e lu r a h a n
d. 1 upa ya 25 4 U paya:
1. K u n ju n g a n
r u m a h o le h
kader
2. P e n y u lu h a n
dengan
TO G A dan
TO M A
3. P e n y u lu h a n
d i K e lo m p o k
D a s a w is m a
4. P e n y u lu h a n
o le h T e n a g a
K e s e h a ta n
5. L a in - la i n
C a ta ta n :
10 J e n is p e n g h a r g a a n b a g i k a d e r b e r u p a : C a ta ta n T P P K K
a . 6 j e n is a t a u le b i h 100 4 D e s a / K e lu r a h a n
b . 4 - 5 j e n is 75 4 1. P ia g a m
c . 1 - 3 je n is 50 4 P e n g h a rg a a n
d. T id a k a d a 25 4 2. P in
3. U ang
 tra n s p o r t
4. M odal U sah a
5. S e ra g a m
6. P e la tih a n
7. L a in - la i n
C a ta ta n :
11 R e n c a n a k e rja P o k j a n a l/P o k ja P o sya n d u I n fo d a n c a ta t a n
T in g k a t ( lin g k a r i n o m o r )
a . 4 tin g k a t 100 4 1. P r o v in s i
b . 3 tin g k a t 75 4 2. Kab /K o ta
c . 2 tin g k a t 50 4 3. Ke ca m atan
d. 1 tin g k a t 25 4 4. D e sa/
K e lu ra h a n
C a ta ta n :
12 P e n e m p e l a n d a n p e n u lis a n s tik e r P 4 K C a ta ta n K e g ia ta n
o le h : Kad er
a. K a d e r d a n P e tu g a s 100 4
b. Kad er 75 4
c. P e tu g a s 50 4
d. T id a k ad a 25 4
C a ta ta n :

C IN D IK A TO R O U T P U T
1 P e r s e n t a s e P e r s a lin a n y a n g d i to l o n g 1. C a ta ta n
FA S IL ITA S k e s e h a ta n se la m a s a tu ta h u n k e g ia ta n T P
a. 90 – 100 % 100 3 P K K D e sa/
b. 70 – 89 % 75 3 K e lu ra h a n
c. 51 – 69 % 50 3 2. C a ta ta n
d. < 50 % 25 3 kader
C a ta ta n :
2 P e r s e n t a s e b a y i d ib e r i A S I E k s k lu s if a. C a ta ta n
s e la m a s a tu ta h u n k e g ia ta n T P
a. 90 – 100 % 100 3 P K K D e sa/
b. 70 – 89 % 75 3 K e lu ra h a n
c. 51 – 69 % 50 3 b. C a ta ta n
d. < 50 % 25 3 kader
C a ta ta n :
3 P e r s e n t a s e C a k u p a n I m u n is a s i B a y i L I L S IP
s e la m a s a tu ta h u n
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
4 P e rse n ta s e S a s a ra n y a n g m e n g g u n a k a n C a ta ta n kader
B u k u K I A s e la m a s a t u t a h u n
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
5 P e r s e n t a s e B u m il y a n g m e n g g u n a k a n R e g iste r S IP
B u k u K I A s e la m a s a t u t a h u n L ih a t J u m l a h Ib u
a. 90 – 100 % 100 3 H a m il
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
6 P e rse n ta s e ru m a h s a s a ra n ya ng d ite m p e l C a ta ta n K e g ia ta n
s tik e r P 4 K Kad er
a. l e b ih d a r i 9 0-10 0% 100 3
 b. 7 0 -8 9 % 75 3
c. 5 1 -6 9 % 50 3
d. < 50% 25 3
C a ta ta n
7 C a k u p a n D / S s e la m a s a tu ta h u n S IP
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
8 C a k u p a n N / D s e la m a s a t u t a h u n S IP
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
9 P e rs e n t a s e a k s e p to r y a n g m e n d a p a tk a n S IP
p e la y a n a n K e lu a r g a B e r e n c a n a s e la m a
s a tu ta h u n
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
10 P e rs e n t a s e a k s e p to r b a ru y a n g p e r ta m a S IP
k a li m e n d a p a t k a n p e la y a n a n K e lu a r g a
B e r e n c a n a s e la m a s a t u ta h u n
a. 90 – 100 % 100 3
b. 70 – 89 % 75 3
c. 51 – 69 % 50 3
d. < 50 % 25 3
C a ta ta n :
11 J u m l a h la y a n a n t e r in t e g r a s i y a n g J e n is la y a n a n
d ila k s a n a k a n d i P o s y a n d u t e r in t e g r a s i
a. 5 la y a n a n a t a u l e b ih 100 3 a n t a r a la i n :
b . 4 la y a n a n 75 3 1. P e n d id ik a n
c . 3 la y a n a n 50 3 A n a k U s ia
d . 1 - 2 la y a n a n 25 3 D in i ( P A U D )
2. B in a
K e lu a rg a
B a lit a ( B K B )
3. P o sy an d u
L a n sia
4. K e la s Ib u
h a m il d a n
b a lit a
5. K o p e ra s i
6. P e r t a n ia n
7. K e t e r a m p il a n
8. K e s e h a ta n
Re p rod u ksi
R e m a ja
9. Tu m b u h A k tif
d a n Ta n g g a p
10. P en g a su h an
P o la M a k a n
Anak
1 1 . P e m a n fa a ta n
Ta m a n O b a t
K e lu a rg a
(TO G A )
1 2 . L a in - la i n
 C a ta ta n :

12 K e t e ra m p ila n k a d e r d a la m K o n s e lin g Sam pel Kad er

k e s e h a t a n d a n G iz i B e r m a in P e r a n
a . T e r a m p il ( P e n g e t a h u a n , T e k n ik 100 3
P e n y a m p a ia n M a te r i, P e n g g u n a a n
M e d ia )
b . C u k u p ( P e n g e t a h u a n , T e k n ik 75 3
P e n y a m p a ia n M a t e r i)
c . K u r a n g ( P e n g e ta h u a n ) 50 3
d . T id a k b is a 25 3
C a ta ta n :
13 K e t e ra m p ila n k a d e r d a la m m e n g is i d a n Sam pel Kad er
m e m ba ca K M S B e r m a in P e r a n
a . T e r a m p il ( P e n g e t a h u a n , C a r a 100 3
M e n g is i, M e m o tiv a s i S a s a r a n )
b . C u k u p ( P e n g e ta h u a n d a n C a ra 75 3
M e n g is i)
c. Ku ra n g (P e n g e tah u an ) 50 3
d . T id a k b is a 25 3
C a ta ta n :
14 K e t e ra m p ila n k a d e r d a la m S IP d a n b a lo k Sam pel kader
SKDN m e n g is i S IP d a n
a . Te r a m p il 100 3 m e m b u a t b a lo k
b. Cu kup 75 3 SKDN
c . K u ra n g 50 3
d . T id a k b is a 25 3
C a ta ta n :
15 K e t e ra m p ila n k a d e r d a la m m e n im b a n g Sam pel 3 kader
b a y i d a n b a lita p ra k t e k
a . Te r a m p il 100 3 m e n im b a n g b a y i
b. Cu kup 75 3 d a n b a lita
c . K u ra n g 50 3
d . T id a k b is a 25 3
C a ta ta n :
16 K e t e ra m p ila n k a d e r d a la m p e n g u k u ra n Sam pel 3 kader
L IL A p a d a ib u h a m il d a n W U S p ra k t e k
a . Te r a m p il 100 3 m e n g u k u r L IL A
b. Cu kup 75 3
c . K u ra n g 50 3
d . T id a k b is a 25 3
C a ta ta n :
 FO R M A T P EN ILAIA N P ELA K SAN A TER B AIK P H B S D I R U M A H T A N G G A

D e s a , K e ca m a ta n :
K a b u p a te n / K o ta :
P ro v in s i :
N a m a P e n ila i :
T a n g g a l P e n ila ia n :
T a n d a ta n g a n p e n ila i :

Nilai N ila i N ila i

No I n d ik a to r S u m b e r d a ta
R iil Bobot Tertimbang
A I n d ik a to r M a s u k a n
1 D u k u n g a n k e b ij a k a n p e n y e le n g g a r a a n B u k ti S K , S u ra t
PHBS E d a r a n , d ll
a . D e sa , k e c a m ata n , k a b /k o ta d a n 100 3
p r o v in s i
b . D e sa , k e c a m a ta n d a n k a b /k o ta 75 3
c . D e sa d a n k e c a m a ta n 50 3
d . T id a k a d a 25 3
2 A d a n y a f o r u m d e s a / k e lu r a h a n . C a ta ta n
k e g ia ta n F o r u m
a . b e r j a l a n r u t in s e t ia p b u l a n 100 3 d e s a / k e lu r a h a n
b . b e r j a la n r u t i n s e t ia p t r iw u la n 75 3
c . b e r j a l a n t e t a p i b e l u m r u t i n s e t ia p 50 3
t r iw u la n
d . a d a t e t a p i b e l u m b e r j a la n 25 3

3 P e m b i a y a a n k e g ia t a n P H B S 1. C atatan T P -
PKK D e sa
a . D e s a d a n k e c a m a ta n , k a b /k o ta d a n 100 3
2. Catatan
p r o v in s i
kader
b . D e sa , k e c a m a ta n d a n k a b /k o ta 75 3
c. D esa, kecam atan 50 3
e . T id a k a d a 25 3
4 S u m b e r p e m b i a y a a n k e g ia t a n P H B S 1. C atatan T P -
PKK D e sa
a . S w a d a y a m a sy a ra k a t, A n g g a ra n 100 3 2. Catatan
D e s a / A P B D , s w a s t a / d u n ia u s a h a kader
dan APBN
b . S w a d a y a m a sy a ra k a t, A n g g a ra n 75 3
D e s a / A P B D d a n s w a s t a / d u n ia
usa ha
 c. S w a d a y a m a sy a ra k a t d a n 50 3
s w a s ta /d u n ia u s a h a
d . S w a d a y a m a sy a ra k a t 25 3
5 K a d e r a k t if m e m b i n a P H B S D i R u m a h
Ta n g g a 1. C atatan T P -
a . L e b ih d a r i 1 5 k a d e r 100 3 PKK D e sa
2. Catatan
b. 11– 15 kader 75 3
kader
c. 6 – 10 kader 50 3
d. 1 -5 k ad er 25 3
6 K a d e r t e r la t i h P H B S
1. C atatan T P -
a. 5 k a d e r a t a u l e b i h t e r la t i h 100 3
PKK D e sa
b. 3 - 4 k a d e r t e r la t i h 75 3 2. Catatan
kader
c. 1 - 2 k a d e r t e r la t i h 50 3
d . T id a k t e r la t i h 25 3

7 M e d i a P e n y u lu h a n P H B S M e lih a t la n g s u n g
m e d ia d i d e s a
a . A d a , u n t u k 7 - 1 0 in d i k a t o r P H B S 100 3
( p o s y a n d u , b a la i
b. A d a , u n t u k 4 - 6 i n d ik a t o r P H B S 75 3 d e s a , d i j a la n
d l l)
c. A d a , u n t u k 1 - 3 in d i k a t o r P H B S 50 3
d. T id a k a d a 25 3

B I n d ik a to r P ro s e s
1 P e la t ih a n P H B S u n t u k k a d e r 100 4 C a ta ta n T P P K K
D esa
a. A d a , u n t u k 5 k a d e r a t a u le b i h 75 4
b. A d a , u n tu k 3 -4 k a d e r 50 4
c. A d a ,u n tu k 1 -2 k a d e r 25 4
d . T id a k a d a p e l a t i h a n

2 R e n c a n a K e g ia ta n P e m b in a a n P H B S d i 1. C a ta ta n T P
R u m a h Ta n g g a PKK D esa
a . A d a , u n t u k 7 - 1 0 in d i k a t o r P H B S 100 4 2. Catatan
kader
b . A d a , u n t u k 4 - 6 in d i k a t o r P H B S 75 4
c. A d a, untuk 1 - 3 in d i k a t o r P H B S 50 4
d. T id a k a d a 25 4

3 M a t e r i P e n y u lu h a n P H B S 1. C a ta ta n T P
PKK D esa
a . A d a , u n t u k 7 - 1 0 in d i k a t o r P H B S 100 4
2. Catatan
b . A d a , u n t u k 4 - 6 in d i k a t o r P H B S 75 4 kader
 c . A d a , u n t u k 1 - 3 in d ik a t o r P H B S 50 4
d . T id a k a d a 25 4
4 M e t o d e P e n y u lu h a n P H B S 1. C a ta ta n T P
PKK D esa
a . K u n ju n g a n r u m a h , p e n y u l u h a n 100 4 2. Catatan
k e lo m p o k , d a n p e n y u lu h a n m a s s a kader
b . K u n j u n g a n r u m a h d a n p e n y u lu h a n 75 4
k e lo m p o k
c . K u n ju n g a n ru m a h 50 4
d . P e n y u lu h a n k e l o m p o k 25 4
5 P e n c a ta ta n P H B S D i R u m a h Ta n g g a 1. C atatan T P -
PKK D e sa
a . A d a , u n tu k s e lu ru h r u m a h t a n g g a 100 4
2. Catatan
b . A d a , u n tu k 7 0 % ru m a h ta n g g a 75 4 kader
c . A d a , u n tu k 6 9 % ru m a h ta n g g a 50 4
d . T id a k a d a p e n c a t a t a n 25 4
6 P e r s e n t a s e r u m a h y a n g d ik u n j u n g i 1. C a ta ta n T P
o le h k a d e r PKK D esa/
a. 9 0 -1 0 0 % ru m ah tan g g a 100 4 K e lu ra h a n
2. Catatan
b . 7 0 -8 9 % ru m ah ta n g g a 75 4
kader
c. 5 1 -6 9 % ru m a h ta n g g a 50 4

d . < 5 0 % ru m a h ta n g g a 25 4

7 F re k u e n s i P e m b in a a n P H B S D i R u m a h 1. C atatan T P -
Ta n g g a d a la m 3 b u la n – 1 ta h u n PKK D e sa
t e r a k h ir 2. Catatan
a . 8 a t a u le b i h 100 4 kader
b. 4 - 7 k a li 75 4
c. 1 - 3 k a li 50 4
d . T id a k a d a 25 4
8 K e t e r a m p ila n k a d e r u n t u k m e n g h it u n g 1. Sam pel
ru m a h ta n g g a b e r P H B S kader
a . T e r a m p il 100 4 menghitung
rum ah
b . C u k u p t e r a m p il 75 4 ta n g g a b e r
c. K u r a n g t e r a m p il 50 4 PH B S.
2. C atatan T P -
d . T id a k t e r a m p il 25 4 PKK D e sa
3. Catatan
kader

9 K e t e r a m p ila n k a d e r m e la k u k a n 1. Sam pel

k u n ju n g a n r u m a h p e n y u lu h a n P H B S kader
a . T e r a m p il 100 4 praktek
 b . C u k u p t e r a m p il 75 4 k u n ju n g a n
rum ah
c. K u r a n g t e r a m p il 50 4
ta n g g a b e r
d . T id a k t e r a m p il 25 4 PH B S.
2. C a ta ta n T P
PKK D esa
3. Catatan
kader

10 F o r u m M u s y a w a r a h D e s a / k e lu r a h a n 1. C a ta ta n T P
m e m b a h a s u p a y a p e m e c a h a n m a s a la h PKK D esa
PHBS 2. Catatan
a. 9 – 1 0 m a s a la h 100 4 kader

b. 7 – 8 m a s a la h 75 4

c. 4 – 6 m a s a la h 50 4

d. 1 – 3 m a s a la h 25 4

C I n d ik a to r L u a ra n
I n d ik a to r T u n g g a l
1 % P e r s a li n a n y a n g d it o l o n g d i f a s ilit a s 1. C atatan T P -
k e se h a ta n PKK D e sa
a. 100 % 100 3 2. Catatan
kader
b. 8 1 -9 9 % 75 3
c. 7 1 -8 0 % 50 3
d. 70 % 25 3
2 % B a y i d ib e r i A S I E k s k lu s if 1. C atatan T P -
PKK D e sa
a. 100% 100 3
2. Catatan
b. 8 1 -9 9 % 75 3 kader
c. 7 1 -8 0 % 50 3
d. 70% 25 3
3 % R u m a h T a n g g a y a n g m e n im b a n g 1. C atatan T P -
b a lit a PKK D e sa
a. 100% 100 3 2. Catatan
kader
b. 8 1 -9 9 % 75 3
c. 7 1 -8 0 % 50 3
d. 70% 25 3
4 % R u m a h Ta n g g a y a n g m e n g g u n a k a n 1. C atatan T P -
a ir b e r s i h PKK D e sa
a . 9 0 -1 0 0 % 100 3
2. Catatan
b. 6 1 -8 9 % 75 3
kader
b. 5 1 -6 0 % 75 3
 c. < 50 % 50 3
5 % R um ah Ta n g ga yan g cu ci tan ga n 1. C atatan T P -
d e n g a n a ir b e r s i h d a n s a b u n PKK D e sa
a . 9 0 -1 0 0 % 100 3 2. Catatan
kader
b. 6 1 -8 9 % 75 3
c. 5 1 -6 0 % 50 3
d. <50% 25 3
6 % R u m a h y a n g m e n g g u n a k a n ja m b a n
seh at 1. C atatan T P -
a . 9 0 -1 0 0 % 100 3 PKK D e sa
2. Catatan
b. 6 1 -8 9 % 75 3
kader
c. 5 1 -6 0 % 50 3
d. <50% 25 3
7 % R u m a h y a n g m e m b e ra n ta s je n tik d i 1. C atatan T P -
rum ah PKK D e sa
a . 9 0 -1 0 0 % 100 3 2. Catatan
kader
b. 6 1 -8 9 % 75 3
c. 5 1 -6 0 % 50 3
d. <50% 25 3
8 % R u m a h ta n g g a y a n g m a k a n s a y u r 1. C atatan T P -
d a n b u a h s e t ia p h a r i PKK D e sa
a . 9 0 -1 0 0 % 100 3 2. Catatan
kader
b. 6 1 -8 9 % 75 3
c. 5 1 -6 0 % 50 3
d. <50% 25 3

9 % R u m a h ta n g g a y a n g m e la k u k a n 1. C atatan T P -
a k t iv it a s f is ik s e t ia p h a r i PKK D e sa
a . 9 0 -1 0 0 % 100 3 2. Catatan
kader
b. 6 1 -8 9 % 75 3
c. 5 1 -6 0 % 50 3
d. <50% 25 3
10 % s e lu r u h a n g g o t a r u m a h t a n g g a t i d a k 1. C atatan T P -
m ero k o k PKK D e sa
a . 9 0 -1 0 0 % 100 3 2. Catatan
kader
b. 6 1 -8 9 % 75 3
c. 5 1 -6 0 % 50 3
d. <50% 25 3
Indikator Gabungan (Komposit)
 % RUM AH TA N G G A B e r-P H B S 1. C atatan T P -
PKK D e sa
a. > 80 % 100 3
2. Catatan
b. 5 0 -8 0 % 75 3 kader
c. < 50 % 50 3
Indikator pemberdayaan
m a s y a ra k a t
A d a n y a U K B M / K e g ia t a n t e r k a it P H B S 1. C atatan T P -
s e c a r a r u t in d il a k s a n a k a n d a la m PKK D e sa
ja n g k a w a k t u s a t u t a h u n 2. Catatan
a . A d a , u n t u k 7 - 1 0 in d ik a t o r P H B S 100 3 kader
3. O b s e rv a si d i
b . A d a , u n tu k 4 -6 i n d ik a t o r P H B S 75 3
la p a n g a n
c. A d a , u n tu k 1 -3 in d ik a t o r P H B S 50 3
d . T id a k ada 25 3

SUB TO TAL

N ila i T a m b a h
a . K e g ia t a n I n o v a s i
(kegiatan pembaharuan atau
p e n g e m b a n g a n y a n g b e lu m
p e rn a h a d a )

a. S it u a s i d a n k o n d is i w il a y a h ( d a e r a h
s u lit / t e r p e n c il/ w il a y a h p e m e k a r a n
a t a u d a e r a h y a n g m u d a h d ij a n g k a u )

TO TAL

C a ta ta n :
1. U ru ta n n ila i d im u l a i d ari n ila i t e r e n d a h y a it u : 25, 50, 75 d an 100 (s esu a i k o n d is i di
la p a n g a n ) s e la n j u t n y a d ik a lik a n d e n g a n n ila i b o b o t = n ila i t e r t im b a n g
2. P e t u g a s p e n ila i s u d a h m e n g is i n il a i t e r t im b a n g p a s c a v e r ik a s i d i la p a n g a n
3. U n t u k D e s a / k e l u r a h a n y a n g m e m il ik i k e g a i a t a n i n o v a s i d i b e r i k a n p e n a m b a h a n n i l a i 5 0 0
 P E N ILA IA N LIN G K U N G A N B E R S IH D A N S E H A T

DESA /KELU RA H AN :
KECAM ATA N :
KABUPATEN/KOTA :
PROVINSI :
JUMLAH
NO IN D IKA T O R N ILA I BOBOT KETERA NG AN
N ILA I
I IN PU T
1 D u k u n g a n k e b ija k a n p e la k s a n a a n
lin g k u n g a n b e r s ih d a n s e h a t
Desa/Kelurahan, Kecamatan, - Catat SK yang ada
a. K a b / K o t a d a n p r o v in s i 100 3 di pokja atau
Desa/Kelurahan, Kecamatan, seketariat PKK
75 3 - Jika SK desa siaga
b. K a b / K o ta
atau lainnya harus
c. D e s a / K e lu r a h a n , K e c a m a t a n , 50 3 tersedia kegiatan
d. D e s a / K e lu r a h a n 25 3 LBS
e. T id a k a d a 0 3
2 D u k u n g a n D a n a d a r i P e m e r in t a h
a. A da 100 3 - Lihat Perencanaan
b . T id a k a d a 0 3
3 D u k u n g a n m a sy a ra k a t
a . D a n a / m a t e r ia l, t e n a g a 100 3 - Lihat Perencanaan
b . D a n a / m a t e r ia l 75 3
c. Te n a g a 50 3
d. T id a k a d a 0 3
4 A d a p o k ja k e s lin g
a . A d a d a n a k t if 100 3 Lihat SK di Pokja
b . A d a d a n k u r a n g a k t if 75 3 Kesling dan bukti
keaktifan (Absensi,
c . A d a d a n t id a k a k t if 50 3 dsb)
d . T id a k a d a 0 3
5 J u m la h d a s a w is m a y a n g a k t if
d ib a n d in g ju m la h y a n g a d a
a. >75% 100 3 - Lihat Catatan
Kerja
b . 5 0 -7 5 % 75 3
c. < 5 0% 50 3
d. T id a k a d a 0 3
6 K a d e r k e s lin g y a n g a k t if
a. > 75% 100 3 -Lihat Catatan Kerja
b . 5 0 -7 5 % 75 3
c. < 5 0% 50 3
d. T id a k a d a 0 3
7 D u k u n g a n k e m itr a a n
a. A da 100 3 -Bukti perjanjian
 kerjasama, dll

b . T id a k a d a 0 3
8 A d a m e d ia p e n y u lu h a n k e s lin g
( P o s t e r, le a f le t , b a n n e r, le m b a r
b a lik , b r o s u r, s p a n d u k , m e d ia
e le k tr o n ik , m e d ia c e t a k , k e s e n ia n
lo k a l)
a . L e b ih d a r i 7 je n is 100 3 Y a n g p a lin g b a n y a k
b . 5 – 7 je n is 75 3 J e n is m e d ia
c. K u ra n g d a ri 5 50 3 m e n ja d i
d. T id a k a d a 0 3 a c u a n p e n ila ia n

J u m la h n il a i
R a t a - r a t a n il a i

II PRO SES
1 P e r e n c a n a a n d i b id a n g k e s lin g
a. A d a p ere ncan aa n d an, 100 L ih a t p e r e n c a n a a n
melibatkan masyarakat, 4 d a n d a f t a r h a d ir
b. A d a p erencanaan 50 4
c. T id a k a d a 0 4
2 P e la k s a n a a n
a. S e lu r u h r e n c a n a k e g ia t a n 100 L ih a t d ila p a n g a n ,
d ila k s a n a k a n 4 w a w a ncara
b. Rencana kerja dilaksanakan 50
s e b a g ia n 4
c. T id a k d ila k s a n a k a n 0 4
3 F r e k u e n s i P e m b in a a n 1 T a h u n
t e r a k h ir
a . 8 k a li a t a u le b ih 100 4 L ih a t c a t a t a n
b . 4 - 7 k a li 75 4
c . 1 - 3 k a li 50 4
d . T id a k a d a 0 4
4 P e m a n t a u a n d a n p e n ila ia n
a . D ila k s a n a k a n o le h p e t u g a s L ih a t h a s il & f o r m a t
d a n k a d e r/m a sy a ra k a t 100 4 p e m a n ta u a n /
b. D ila k s a n a k a n o le h p e t u g a s 75 4 k a rtu ru m a h
c. D ila k s a n a k a n o le h
k a d e r/m a sy a ra k a t 50 4
d. T id a k A d a 0 4

J u m la h n il a i
R a t a - r a t a n il a i

III OUTPUT
1 C akup an R um a h se hat
a. 100% 100 3 M e m e n u h i k r it e r ia
 R um ah sehat

b. 9 0 -9 9 % 75 3
c. 7 0 -8 9 % 50 3
d. <70% 25 3
2 A k s e s a ir b e r s i h / m i n u m
a. 100% 100 3
b. 9 0 -9 9 % 75 3
c. 7 0 -8 9 % 50 3
d. <70% 25 3
3 A k s e s S a n it a s i/ J a m b a n
a. 100% 100 3
b. 9 0 -9 9 % 75 3
c. 7 0 -8 9 % 50 3
d. <70% 25 3
4 Cakupan SPAL
a. 100% 100 3
b. 9 0 -9 9 % 75 3
c. 7 0 -8 9 % 50 3
d. <70% 25 3
5 P e n g e lo la a n S a m p a h
a . A d a p e m il a h a n p e m a n f a a t a n ,
T P S , T P A d a n p e n g a n g k u ta n
t e r ja d w a l 100 3 B u k t i f is ik ( F o t o )
b . A d a p e n g u m p u la n d a n 50 3
p e n g a n g k u ta n (k o ta), d a n a d a
lu b a n g s a m p a h ( d e s a )
c . D ik u m p u lk a n s a ja 25 3
6 J a la n L in g k u n g a n
a. S e m u a L in g k u n g a n B e r s ih ,
R a p ih d a n t id a k a d a 100
genangan 3 B u k t i f is ik ( F o t o )
b. S e b a g ia n ja la n li n g k u n g a n
b e r s ih d a n r a p i t id a k a d a
genangan 50 3
c. S e b a g ia n ja la n li n g k u n g a n
b e r s ih d a n r a p i, t e t a p i a d a
genangan 25 3
7 D r a in a s e
a. M e n c a k u p s e lu r u h w ila y a h 100 3
d e s a / k e lu r a h a n a lir a n a ir
la n c a r t id a k t e r g e n a n g B u k t i f is ik ( F o t o )
b. M e n c a k u p s e b a g ia n w ila y a h 50 3
d e s a / k e lu r a h a n a lir a n a ir
la n c a r t id a k t e r g e n a n g
c. M e n c a k u p s e b a g ia n w ila y a h
d e s a / k e lu r a h a n a lir a n a ir
k u r a n g la n c a r, a d a g e n a n g a n 25 3
8 P e n a ta a n p e k ara n g a n
a . M e n c a k u p s e l u r u h w ila y a h
d e s a / k e lu r a h a n
p e k a r a n g a n n y a r a p i ( t id a k
a d a sa m p a h b e rs e ra k a n ) d a n
te ra w a tt 100 3 B u k t i f is ik (F o to )
b. S e b a g ia n p e k a r a n g a n r a p i t a p i
k u r a n g b e r s ih 50 3
c. S e b a g ia n p e k a r a n g a n
k u ra n g ra p i d a n
k u ra n g b e rs ih 25 3
9 P e n g h ija u a n d a n p e m a n fa a t a n
p e k a ra n g a n
a. M e n c a k u p s e l u r u h w ila y a h 100 3
d e s a / k e lu r a h a n a d a
p e n g h ija u a n d a n
p e m a n fa a ta n p e k a ra n g a n
( u n t u k t a n a m a n , k o la m ik a n ,
dsb) B u k t i f is ik (F o to )
b. S e b a g ia n w il a y a h
d e s a / k e lu r a h a n a d a
p e n g h ija u a n d a n
p e m a n fa a ta n p e k a ra n g a n
( u n t u k t a n a m a n , k o lo m ik a n ,
dsb) 50 3
c. H a n y a p e n g h ija u a n 25 3

10 A n g k a b e b a s j e n t ik (Aedes sp)
a. >95% 100 3
b. <95% 0 3

J u m la h n ila i
R a ta - ra ta n ila i
N ila i A k h ir

C a ta ta n :
1 I n o v a s i : K e g ia t a n y a n g b e lu m a d a d i t e m p a t la i n
2 K r e a t iv it a s : K e g ia t a n y a n g s u d a h a d a d i t e m p a t la i n