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7/26/2019 Form Rumah Sakit Dan Puskesmas
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7/26/2019 Form Rumah Sakit Dan Puskesmas
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@. +rin8n int0i " . Amn (e 4r4nne4tin#
=
. Ter0in%n8 *
1 2 3 4 5 61. S0rn ir 0im! 1 . Ter0in%n8 *
. Tertt5
. A0irn ir 0n4r
II RUANG BANGUNAN(Ju!"# B$%$& 1' )
1 Rn8 5er'tn 2 . R%i 0 0nti%en8n tem5t ti%r :- De' : *" m2/tt
- An6 /&i : 2 m2/tt
2
. R%i tem5t ti%r%en8n 6mr mn%i 1-1 tt/6mr mn%i %n ti0et
1
4 An86 6mn 1
7/26/2019 Form Rumah Sakit Dan Puskesmas
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0n8it 2"> 3"3 m %ri 0nti
e. Keiin8n =?%BA
1
*. Rn8 teri0ii 1" . Pint m6
ter5i! %en8n 5int 6e0r
. Tere%i rn86!
3
4. Din%in8 tert%ri 5re0in / 6ermi6 etin88i 1"m %ri 0nti
2
. Rn8 r%i08i " . Din%in8 %n%n 5int %i05ii tim! !itm
3
. K4 en%e0
men88n6n 64 tim! !itm
3
4. Tin88i 0n8it 0n8it
2
%. Hn8n%en8n rn8 8e05 !r %en8n06et
2
=. Rn8 5en%in8in 1 . S! 1 C /% E C
. Be ti6 / 6e46 *
4. Di0en865i r6 nt6 men&m5n
m6nn %en8n tin88i 2-2
1
7/26/2019 Form Rumah Sakit Dan Puskesmas
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e4r 6teri 08i memen!i&rt
2. Tem5t 5en&im5nnm6nn %n m6nn
%i
3 . M6nn &n8m%! mem6 %iim5n 5%
! ="C t *C
3
. M6nn &n8 6n%ii6n = m %i im5n 5%! -C /% 1C
3
4. Beri! 1
%. Ter0in%n8 %ri %e 1
e. Be %ri8n88n ern88 %n ti6
1
7. B!n m6nn %n
m6nn %i ter5i!
1
3. Pen&in m6nn 2 . Men88n6n 6eret%rn8 tertt5
. Ti%6 men&i6nm6nn %i &n8 %!men8in5
*
4. L0 0int m6nn%i men88n6n 0r 6!
1
*. Tem5t 5en80!n
0!n m6nn (%5r#
2 . Lnti %5r
ee0m %n e%! 6e8itn%ieri!6n %en8n nti e5ti4
. Di0en865i %en8nn865 %n 4ern8 5
2
4. Pen4!&n 2 2
7/26/2019 Form Rumah Sakit Dan Puskesmas
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7/26/2019 Form Rumah Sakit Dan Puskesmas
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VIII STERILISASI ALAT DANPERLENGKAPAN MEDIS
1 . Men88n6n 5er0tn teri0ii5 (t409e# / 8 %en8n !e6itr 132C t. Per0tnrii 8e0mn8 mi6r
(mi6r'9e# t %en8n 4r 0in&n8 memen!i &rt.
*
. A0t %n 5er0en865n me%i &n8%! %iteri06n t %i im5n5% tem5t 6! &n8 teri050
3
4. A0t %n 5er0en865n 65nme%i &n8 %! %iteri06n t%i%ein7e6i ter0ei! %!0 %i
eri!6n %ri %er!. +rin8nt! %n i !n 0in
2
%. Per0tn teri0ii %i60iri min.e60i/t!n
1
I PERLINDUNGAN RADIASI 2 . Int0i %n 8%n8 5er0tnr%ii %i tem5t6n 5% 06i&n8 ! %ri tem5t &n8 r'n6e6rn" tem5t er6m50rn8 n&6
. Te0 !n 5er0in%n8n 5%min8 min8 rn8ner%r6n eni ener8i r%ii"6ti7it %imeni mer r%iiert i7t !n 5er0in%n8 ei
7/26/2019 Form Rumah Sakit Dan Puskesmas
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(.#
NIP :
K,T,RANAN :
$$$$$ # Cret &n8 ti%6 5er0
7/26/2019 Form Rumah Sakit Dan Puskesmas
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7/26/2019 Form Rumah Sakit Dan Puskesmas
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Den8n 4r 6re minim0 nt6 min8-min8 9rie0 5& %0! e5erti teret 5%te0 eri6t :
TYPEKLAS
RS
SKORE MINIMAL DARI MASING:MASING VARIABEL UPAYA(D"!" ;)
I II III IV V VI VII VIII I I
A $# > > @ ? ? ? > 1 = =
B $# > > @ ? ? ? > 1 = =
C $# > > @ ? ? 2 > = =
D $# > > ? ? ? 2 > = 2
7/26/2019 Form Rumah Sakit Dan Puskesmas
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7/26/2019 Form Rumah Sakit Dan Puskesmas
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1. P8r 1 . A%n& 58r 0in86n8n &n8memti m&r6t %en8nn8nn P6em
. P8r 6t %n eri!
4. Ti%6 % 8in 58r &n8r6.
%. A%n& 5int m6 / 6e0r
3
3
2
2
2. H0mn (tmn" 0n %n tem5t 5r6er
1 . A%n& tmn. A%n& tem5t
5r6ir4. H0mn" tmn %n
tem5t 5r6ir tm56 eri!%. Tmn %i5e0i!r%n tertt r5i
e. Tere%i tem5tm5! ementr
212
32
3. Ter 2 . Ter %n 0ntiti%6 ret6
. Beri!4. Ke%5 ir %. M%! %ieri!6n
3322
*. Din%in8 0r n8nn * . Ti%6 ret6 P 6 t
32
7/26/2019 Form Rumah Sakit Dan Puskesmas
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II. BANGUNAN DALAM (Bt 1#
KOMPONEN YANG DINILAI
VARIABEL UPAYA KESEHATAN LINGKUNGAN KETERANGAN
N2!"2
R.
4,
.Pu64
R.
R","&
R.
T"&"U6"#"
R.
P-1"
>&"3"-
R.T
u-0u
P
$!.KB
P$
!.G202
P$!.Uu
P$!.KIA
P$
!.G2?2
A,$&24
L"%$3"&$32u
Gu1"-0
D",u3
T$2!&
R"@"&I-",
Ju!"#
1 2 3 4 5 6 8 9 1' 11 12 13 14 15 16 18 19 1 2'
1. DINDING. Ti%6 ret6. Pern6n rt4. Ct er'rn tern8
(5ti!/6rem#%. Beri! %ri n% / 4retn
e. Tert %ri 5re0in (min 1"#
Km5nen %in%in8tert %ri 5re6! 0rtrim
31
3
1
2+m0!
Bt 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
S4re 2
2. PINTU JENDELA KAA 7 VENTILASI. D0m 6e%n i6. Pint %5t men4e8!
m6n& ern88 / 6e464. K4 en%e0 eri! %n ti%6
5e4!%. )enti0i tere%i er7n8i %n
menmin r n&mn
32
32
+m0!
Bt 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3S4re 2
7/26/2019 Form Rumah Sakit Dan Puskesmas
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1 2 3 4 5 6 8 9 1' 11 12 13 14 15 16 18 19 1 2'
3. ATAP DAN LANIT-LANIT. Ln8t-0n8it minim0 2" M %ri
0nti. Ln8it-0n8it rt %n ti%6
ret64. At5 ti%6 4r
%. M%! %ieri!6ne. Beri!
2
1
32
2
+m0!
Bt 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
S6re 3
*. LANTAI. Rt %n ti%6 ret6. Beri!4. Ke%5 ir %. M%! %ieri!6n
23
3
2
+m0!
Bt
S6re .*
. TATA RUANAN DAN P,N,RANAN. Penern8n 465 nt6
mem4 5% %r 50in8 8e05. Pentn rn8n r5i
+m0!
Bt * * * * * * * * * * * * * * * * *
S4re
N!" C$ (1 2 3 4 5)
Keterangan :Nilai = Jumlah dikalikan bobot
1 2 3 4 5 6
III SARANA +ASILITASSANITASI
7/26/2019 Form Rumah Sakit Dan Puskesmas
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(Bt *3#1. Pen&e%in ir 1 . Tere%i ir eri!
%0m m0! &n8 465 (1" 1"? M3#
. Memen!i &rt60it ir eri!
4. Ditrii irmen88n6n 5er5i5n
%. Tere%in&n 6
44i tn8n 5% nit 5e0&nnPemeri6n KIA-KB" Rn8 i8i"Lrtrim
3
3
1
3
2. +mn / 6mr mn%i @ . Tere%in& 6mrmn%i %n C nt6 6r&'n (1: 1#
. Kmr mn%i %n66 6r&'n 5ri %n 'nitter5i!
4. Tere%in& 6mrmn%i %n 66 5en8nn8
%. Beri!" ti%6 e. S0rn
5emn8n ir 0im! %in86e Se5ti4 Tn6
7. Ri 6mr mn%i/66 %en8n tem5t ti%r (1:#(K! P6em Per'tn#
2
1
1
22
2
3. SPAL ? . A%n& 0rnSPAL
. Ber7n8i4. Air 6tr %ri 6mr
mn%i %n rn8n 5e0&nn%i0ir6n 6e SPAL
%. S0rn ir 0im!tertt5
e. Dn 6e%5 ir
222
22
*. Sm5! 1 . A%n& tem5tm5! %i ti5-ti5 rn85e0&nn
. Tem5t m5!6e%5 ir
2
23
7/26/2019 Form Rumah Sakit Dan Puskesmas
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4. A%n& 5emi!nm5! In7e6i %n nnIn7e6i
%. Pen8n8nm5! eti5 !ri (1 60i 2* m#
e. Penn8nnm5! in7e6i men88n6n5n tin88i
2
1
. t7e0 = . Tere%in& 't7e0
. Ber7n8i %en8ni6
4. Tere%i 5%5e0&nn KIA-KB Lrtrim"P0i i8i / R. Per'tn
%. Tere%i Gt ntie5ti6
e. A% 05 5en8erin8.
2
22
22
IV MANAJEMEN DALAMKEBERSIHAN DAN
KETERANGAN (B$%$& < 22)1. Pen80!n PPBT 1 . %n& r8nii P6 PPBT 2
. % 5e%mn PPBT4. % 5enrn rin t8 56
PPBT
21
%. % !i0 5eni0in PPBT eti50n
1
e. % ri5 05rn PPBT 6e Dti IIeti5 3 0n
1
7. % 5eminn 2
8. Tere%in& 0t 0t 6eeri!n6etertin P6em
1
2. Penm5i0n T8 * . Penm5i0n r5i %n eri! 2
. P6in er8m 34. Mem6i trit 0en865 3
%. Beri65 rm! 23. Dii50in 5et8 * . A%& 6 tm 1
7/26/2019 Form Rumah Sakit Dan Puskesmas
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. %n& %7tr !%ir 58i %n re 24. % rin t8 eti5 5et8 *
%. !%ir %n 50n8 te5t '6t 3
*. Ketertin * . A0r nit 5e0&nn tertr 2. % 55n nm P6em 2
4. % 55n nm rn8 %i intirn8
2
%. % 5et8 5i6et *
V RUANG TAMBAHAN * . %n& rn8 r5t teren%iri *
. %n& m!0 *4. % rn8 / tem5t nt6 6e8itn
0! r82
Men8et!i : Pet8 Pen8' / Pemeri6
K. Din. Ke. Pr5. Dti 1/ 1. Nm : ...
K/K%& Dti 11 $$$$
(.#
.. NIP :
2. Nm : ...
(.#
NIP :
3. Nm : ...
(.#
NIP :
K,T,RANAN :
$$$$$ # Cret &n8 ti%6 5er0
PETUNJUK PENGISIAN +ORMULIR PENILAIAN DAN PELAPORAN
PUSKESMAS BERSIH DAN TERTIB
7/26/2019 Form Rumah Sakit Dan Puskesmas
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A. PENILAIAN PPBT
A5e6 5eni0in ter%iri t :
. Peni0in 6n%ii 7ii6 56em me0i5ti : 8in 0r. B8in %0m 56em %n rn 7i0it niti %n rn8 tm!n
%. Peni0in 5e6 Mn8emen 6eeri!n %n 6etertin 56em me0i5ti : 5en80!n PPBT" 5enm5i0n 5et8. Dii50in 5et8 %n 6eterti
Srn 5e06nn 5eni0in 56em eri! terti %i 8n6n intrmen 5eni0in %n 6etern8n e8i eri6t :
. Intrmen PPBT %i 56i nt6 5eni0in 6e5% rn 56em" 56em %en8n 5er'tn (DTP# %n 56em 5emnt.
- Unt6 56em DTP : Ter%iri nmr %en8n 3@* 5m5nen 5eni0in
- Unt6 56em : Ter%iri nmr %en8n 3>2 6m5nen 5eni0in
- Unt6 56em 5emnt : Km5nen &n8 %ini0i 5% 9rie0 5& &n8 ti%6 %i066n 5eni0in %0m 5e06nn PPBT ini %ie6n 6ren
5e0&nn &n8 tert" m6 nt6 6m5nen &n8 %ini0i ti%6 term6 %0m 5eni0in J e!in88 6re m6im0 %i 6rn8i %en8n 6re m6im0 6m
ni0i.
%. K$,$-- /"-0 - !"
A5i0 6en&tn &n8 % ti%6 memen!i 5er&rtn e8imn ter4ntm 5% 6m5nen &n8 %ini0i" m6 ni0in& (n0#" e0i6n& 5i0 meme
m6 ni0in& %0! eer ni0i &n8 ter4ntm.
V""%! U,"/"
C. )rie0 eti5 8in t eti5 6e8itn %ri 9rie0 5& memi0i6i ni0i ntr (n0# m5i %en8n 1.
. S$
S6re %0! 5er60in ntr t %en8n ni0i &n8 ter4ntm
. Tt0 e0r! !i0 5eni0in 6em%in %im0!6n
-Ni0i m6im0 nt6 56em DTP : 3@*
- Ni0i m6im0 nt6 56em : 3>2
- Ni0i m6im0 nt6 56em Pemnt : 5eni0in m %en8n 5eni0in 56em %en8n eer5 !0 %iei6n %en8n 6n%ii 90me 6e8i
5emnt. Unt6 6m5nen &n8 %ini0i 5% 9rie0 5& &n8 ti%6 %i066n 5eni0i 5% 56em 5emnt 6ren 6etertn 6emm5n nt
7/26/2019 Form Rumah Sakit Dan Puskesmas
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6e8itn 5e0&nn" m6 nt6 6m5nen &n8 %ini0i ti%6 term6 %0m 5eni0in J e!in88 6re m6im0 %i6rn8i %en8n 6re m6im0 %i6rn
m6im0 &n8 %ini0i
>. Penentn 6riteri 0&6 e!t
- P6em DTP : >
: P6em : =
: P6em 5emnt : =
B. P!",$"- PPBT
1. Tin86t 56em
Pe05rn %ri 56em 6e Dti II %i06n6n eti5 = 0n &it 5% 0n +nri %n 0n +ni.
2. Tin86 Dti II
Pe05rn %ri Dti II Pr5ini %i06n6n eti5 = 0n &it 5% 0n
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