1.form Monitoring Dan Evaluasi - Puskesmas

 

ODYM MDKGUDYGKJ ENK B_N@RNXG VBKHBJNCNK ENK VBKJBKEN@GNK VBKWNAGU UGENA MBKR@NY (V9VUM) EG VRXABXMNX

Unkjjn`

< 9> / 6?. / 969>.

Knmn Vusab sabsmn smns

< .………… ………………….…

Eggsg d`bc < …………………

Adeb Zg`/Vusabsmns Zg`/Vusabsmns < .…………………….… .…………………….…  N`nmnt

< L`. ……………………... …………………….........Ab`… ......Ab`………………… …………………Abh……… …Abh……………........ ……........

Ani………………………………………......Vrdv……………………............................................ Ub`p………………….……………… Onx ….…………………………bmng`...................................

Ugpb Ugpb Vusa Vusabs bsmn mns s

< Kdk Kdk pb pbrn rnwn wntn tnk k Wn Wn / Ugen Ugena. a.

Ubmpnt Ugeur

<

Cnrg pb pb`nynknk

< ... ... ... cnrg/ mgkjju

Lum`nc Vbkeueua

< ... ... ... drnkj

@uns @uns wg wg`n `nyn ync c abr abrln ln

< .... .. .. .... .... .. am9

Vbrn Vbrnwn wntn tnk k Wn Wn / Ugen Ugena a

>. Entn XE XEM

Lbkgs XEM

n. i. h. e. b. o. j.

Lum`nc

Edatbr Vbrnwnt Igenk Vbtujns absbcntnk admukgtns/ pbkyu`uc absbcntnk  Nc`g jgzg Bpgebmgd`dj Adksb`dr/Vsgad`dj

c. g.

 l. Ubknjn `ngkkyn <  

…………………………..

>

 

9. ENUN ENUN VBKER VBKERARK ARKJ J ABJGNU ABJGNUNK NK V9VU V9VUM M

>) Vdstbr Vdstbr ( tbrsbeg tbrsbegn n / tgen tgena a / aurnkj aurnkj ) Lgan Wn, sbiutank < ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... 9) @bminr @bminr in`ga in`ga ( tbrsbeg tbrsbegn n / tgena tgena / aurnkj aurnkj ) Lgan Wn, sbiutank < ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... 8) Inkk Inkkbr br ( tbrs tbrsbe begn gn / tge tgena na ) Lgan Wn, sbiutank < ................................... ....................... ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... 5) @bno` @bno`bt bt ( tbrsbe tbrsbegn gn / tge tgena na ) Lgan Wn, sbiutank < ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ......

2) Og`m / _gebd _gebd VUM (tbrsbe (tbrsbegn gn / tgena) tgena) Lgan Wn, sbiutank < ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ ........................ .............. ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ ........................ .............. ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ................ .... ?) Vbedmn Vbedmnk k / Luakgs Luakgs VVUM VVUM ( tbrsbe tbrsbegn gn / tgen tgena a) Lgan Wn, sbiutank < ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... ....................... ........... ........................ ........................ ......................... ......................... ......................... ......................... ........................ ........................ ........................ .................. ...... 9

 

8. Vbkj Vbkjbke bken`g n`gnk nk Onatd Onatdrr Ygs Ygsgad gad VUM VUM >) Abtbrsb Abtbrsbegnn egnnk k mntbrg, mntbrg, gkodrmns gkodrmnsgg enk beuans beuansgg VUM

Mntbrg -

Nen

Ugena

Rpny Rpnyn n Ibrc Ibrcbk bktg tg mbrd mbrdad ada a Jg Jgzg zg sbcn sbcntt e enk nk sbgm sbgmin inkj kj Mbkj Mbkjcg cgke kenr nrgg n`ad n`adcd cd`` Natg Natgvg vgtn tns s ogsg ogsga a / d`n d`nc c rnjn rnjn Vbkn Vbknkj kjnk nknk nk mnk mnkeg egrg rg egn egnib ibtbs tbs enk enk

pbkynagt ardkga `ngkkyn - On Onatd atdrr rgsgad rgsgad ank ankab abrr pnyue pnyuenrn nrn enk enk `bcb `bcbrr rncgm enk hnrn mbkebtbasgkyn - Mntb Mntbrg rg `ng `ngkk kkyn yn,, sbiu sbiuta tank nk < 9) Vbkbrnpnk Vbkbrnpnk Anwnsnk Anwnsnk Unkpn Unkpn Ydada Ydada (AUY) (AUY) eg wg`nync wg`nync abrln Vusabsmns Vusabsmns

Kd

Untnknk

Lum`nc

Lum`nc AUY

(Udtn`)

(Wnkj suenc mbkbrnpank)

>. Onsynkabs*) 9. Ubmpnt Abrln 8. Ub Ubmp mpnt nt Ib`n Ib`nln lnrr Mbkj Mbkjnl nlnr  nr  5. Ubmp Ubmpn nt Ibrmn rmngk nkna 2. Onsg`gtns Rmum ?. Nkjautnk Rm Rmum :. Ubmpnt GGi inenc *)Onsynkabs ynkj nen eg wg`nync abrln pusabsmns

5. Vbmn Vbmnkon konntn ntnk k @ny @nynk nknk nk VUM VUM

Kd Abjgntnk Vbkjbken`gnk VUM >. Lum` Lum`nc nc td tdtn tn`` aukl aukluk ukjn jnk k Vusa Vusabs bsmn mns s 9. Lu Lum` m`nc nc td tdtn tn`` au aukl kluk ukjn jnk k VUM VUM 8. Lum` Lum`n nc pbkyu` yu`ucnk VUM 5. Lum`nc ruluank VUM 2. Lum` Lum`n nc ru rulu lua a in`ga `ga VUM ?. Lu Lum` m`nc nc au aukl kluk ukjn jnk k `nyn `nynkn knk k RIM* RIM*)) :. Lum`n Lum`nc c a`gbk a`gbk ynkj ynkj ibrcn ibrcnsg` sg` ibrcb ibrcbktg ktg mbrda mbrdada da 2. Abjgn Abjgntnk tnk VVUM VVUM eg eg Vusa Vusabs bsmn mns s

8

Lum`nc tdtn` sntu tncuk

 

Kd >

Lbkgs abjgntnk Vbkyu`ucnk VVUM

9

Ebtbasg Egkg VUM

8

Vb`ntgcnk anebr  

Lum`nc pbrtncuk

Enk `ngk-`ngk

?. Vdsigke Vdsigkeu u VUM eg wg`nyn wg`nync c abrln abrln Vusabsm Vusabsmns ns

>. Lum` Lum`nc nc Vdsi Vdsigk gkeu eu VUM VUM Lum`nc Vdsigkeu VUM eg wg`nync abrln Vusabsmns < …………… Vdsigkeu Lum`nc Ab`urncnk eg Zg`nync Abrln Vusabsmns

< ................... ............ ....... Ab`urncnk

Lum`nc Ab`urncnk ynkj mbmg`gag Vdsigkeu VUM

< .................... ............ ........ Ab`urncnk

Lum`nc Vdsigkeu Agt eg wg`nync abrln Vusabsmns

< ..................... ............ .........

Kd

Vusabsmns

Lum`nc Vdsigkeu

Lum`nc

Adkegsg N`nt

Vdsigkeu

Vdsigkeu Inga Iurua

Agt

>.

Kd.

Knmn

KGV

Unkentnkjnk

5

Kd Ub`p/ bmng`

 

>.

………… …………………

……………………

…………………..

………… ………………..

9.

…………………..

……………………

…………………..

…………………

2